Basic Information
| Provider Information | |||||||||
| NPI: | 1356490486 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOVANOVICH | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 9TH AVE | ||||||||
| Address2: | MS M4-PA | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981012756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065155811 | ||||||||
| FaxNumber: | 2065155886 | ||||||||
| Practice Location | |||||||||
| Address1: | 33501 1ST WAY S | ||||||||
| Address2: | |||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980036208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538382400 | ||||||||
| FaxNumber: | 2538741634 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 12/31/2012 | ||||||||
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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 | 363AS0400X | PA10004066 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 970030800 | 01 | WA | RAILROAD MC# | OTHER | 0335JO | 01 | WA | BLUE SHIELD # | OTHER | 8362543 | 05 | WA | MEDICAID | 0039594 | 01 | WA | LABOR AND INDUSTRIES # | OTHER | US7233432 | 01 | WA | AETNA SPECIALIST PIN | OTHER |