Basic Information
| Provider Information | |||||||||
| NPI: | 1689749624 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HABENICHT | ||||||||
| FirstName: | TEI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4409 NW ANDERSON HILL RD | ||||||||
| Address2: | |||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983836807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606986630 | ||||||||
| FaxNumber: | 3603987002 | ||||||||
| Practice Location | |||||||||
| Address1: | 4409 NW ANDERSON HILL RD | ||||||||
| Address2: | |||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983836807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606986630 | ||||||||
| FaxNumber: | 3603987002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2006 | ||||||||
| LastUpdateDate: | 04/04/2012 | ||||||||
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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 | PA10004580 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 0277669 | 01 | WA | L&I | OTHER | 1037226 | 05 | WA | MEDICAID |