Provider Demographics
NPI:1366727976
Name:MOCK, STEVEN DECIERDO (PA-C)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:DECIERDO
Last Name:MOCK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-0001
Mailing Address - Country:US
Mailing Address - Phone:253-968-4000
Mailing Address - Fax:
Practice Address - Street 1:MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1098271363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant