Organization
EVERGREEN CHILDREN'S CLINIC, PLLC
Active
Other names
Pediatrics PM
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. SUSANNE I ROACH (OFFICE MANAGER)
(253) 848-2303
Entity
Organization
Contact information
Practice address
1910 S MERIDIAN, SUITE A, PUYALLUP, WA 98371-7531
(253) 848-2303
(253) 848-8956
Mailing address
1910 S MERIDIAN, SUITE A, PUYALLUP, WA 98371-7531
(253) 848-2303
(253) 848-8956
Taxonomy
Speciality
Code
Description
License number
State
2080A0000X
Pediatric Adolescent Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
7054364
—
WA
Enumeration date
12/27/2006
Last updated
08/22/2020
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