Basic Information
Provider Information | |||||||||
NPI: | 1063468403 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VASCIK | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 505 S 336TH ST. | ||||||||
Address2: | SUITE 600 | ||||||||
City: | FEDERAL WAY | ||||||||
State: | WA | ||||||||
PostalCode: | 980036328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2538386180 | ||||||||
FaxNumber: | 2538386418 | ||||||||
Practice Location | |||||||||
Address1: | 1717 SOUTH J STREET | ||||||||
Address2: |   | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984054933 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2534266660 | ||||||||
FaxNumber: | 2534266250 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/26/2006 | ||||||||
LastUpdateDate: | 11/21/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | PA10004026 | WA | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 363A00000X | PA10004026 | WA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 0154972 | 01 | WA | LIWA | OTHER | 2165VA | 01 | WA | BSWA | OTHER | 2164VA | 01 | WA | BSWA | OTHER | BSWA | 01 | WA | 7022VA | OTHER | 0190072 | 01 | WA | LIWA | OTHER | 0206067 | 01 | WA | LIWA | OTHER | 8349052 | 05 | WA |   | MEDICAID |