Basic Information
| Provider Information | |||||||||
| NPI: | 1508861709 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EGGE | ||||||||
| FirstName: | NOELLE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3325 GLENDALE DR W | ||||||||
| Address2: | |||||||||
| City: | UNIVERSITY PLACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984662226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083856085 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9505 S STEELE ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984441858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535976800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2005 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1834 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 42867900 | 05 | WI | MEDICAID |