Provider Demographics
NPI:1679617534
Name:DICK, MIRIAM R (PA)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:R
Last Name:DICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34584
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1584
Mailing Address - Country:US
Mailing Address - Phone:509-241-7349
Mailing Address - Fax:509-241-7628
Practice Address - Street 1:310 15TH AVE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-5103
Practice Address - Country:US
Practice Address - Phone:206-326-3207
Practice Address - Fax:206-326-2116
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAPA10000164363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8356735Medicaid
WA8356735Medicaid
WAP03037Medicare UPIN