Provider Demographics
NPI:1154727501
Name:ELLIOTT, MICHAEL JIOVANNI (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JIOVANNI
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 5215
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98415-0215
Mailing Address - Country:US
Mailing Address - Phone:253-403-1050
Mailing Address - Fax:253-403-1717
Practice Address - Street 1:315 MLK JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405
Practice Address - Country:US
Practice Address - Phone:253-403-1050
Practice Address - Fax:253-403-1717
Is Sole Proprietor?:No
Enumeration Date:2014-11-12
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60511930363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant