Basic Information
| Provider Information | |||||||||
| NPI: | 1366421174 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRIESKORN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | RUSSELL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1668 | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985845001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604261611 | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 MOUNTAIN VIEW DR | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985844401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604261611 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 03/03/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA10004942 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 8466955 | 05 | WA | MEDICAID |