Provider Demographics
NPI:1043433352
Name:GOUDELOCK, PENNY (PA)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:GOUDELOCK
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 1:18012 W VALLEY HWY
Mailing Address - Street 2:STE 101
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-2924
Mailing Address - Country:US
Mailing Address - Phone:425-291-3300
Mailing Address - Fax:425-291-5300
Practice Address - Street 1:1100 PACIFIC AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4261
Practice Address - Country:US
Practice Address - Phone:425-388-4075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005160363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8485898Medicaid
WAG8871763Medicare PIN
WA8485898Medicaid
WAG8866482Medicare PIN