Basic Information
| Provider Information | |||||||||
| NPI: | 1801807128 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUTH | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C, L.AC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7210 40TH ST W | ||||||||
| Address2: | STE 100 | ||||||||
| City: | UNIVERSITY PLACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984664318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535640170 | ||||||||
| FaxNumber: | 2532074240 | ||||||||
| Practice Location | |||||||||
| Address1: | 7210 40TH ST W | ||||||||
| Address2: | STE 100 | ||||||||
| City: | UNIVERSITY PLACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984664318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535640170 | ||||||||
| FaxNumber: | 2532074240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171100000X | AC00002753 | WA | X | Other Service Providers | Acupuncturist | 363A00000X | PA10002261 | WA | X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.