Basic Information
| Provider Information | |||||||||
| NPI: | 1588084495 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | JANEL THIEL | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | THIEL | ||||||||
| OtherFirstName: | TIFFANY | ||||||||
| OtherMiddleName: | JANEL | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2422 FRUITLAND RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983716002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093080619 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 315 MARTIN LUTHER KING JR WAY | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534031000 | ||||||||
| FaxNumber: | 2532741685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2014 | ||||||||
| LastUpdateDate: | 07/13/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD60936506 | WA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.