Provider Demographics
NPI:1043456684
Name:RODGERS, MICHELLE LYNN (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:LYNN
Last Name:RODGERS
Suffix:
Gender:F
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 1:3600 LIND AVE SW
Mailing Address - Street 2:SUITE 100 ATTN CREDENTIALING
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057
Mailing Address - Country:US
Mailing Address - Phone:425-690-2715
Mailing Address - Fax:
Practice Address - Street 1:24920 104TH AVE SE
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030
Practice Address - Country:US
Practice Address - Phone:425-690-3420
Practice Address - Fax:425-690-9420
Is Sole Proprietor?:No
Enumeration Date:2009-01-04
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60570863363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8963551OtherMEDICARE
WA2049501Medicaid