Basic Information
| Provider Information | |||||||||
| NPI: | 1679767677 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARREON | ||||||||
| FirstName: | MYRA | ||||||||
| MiddleName: | DREW | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1708 YAKIMA AVE STE 107 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532074850 | ||||||||
| FaxNumber: | 2538585436 | ||||||||
| Practice Location | |||||||||
| Address1: | 1708 YAKIMA AVE STE 107 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532074850 | ||||||||
| FaxNumber: | 2538585436 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2007 | ||||||||
| LastUpdateDate: | 12/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | ME107431 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | MD60672218 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 2072238 | 05 | WA | MEDICAID |