Provider Demographics
NPI:1093771537
Name:SUWARNO, NEIHL OMAR (PA - C)
Entity Type:Individual
Prefix:
First Name:NEIHL
Middle Name:OMAR
Last Name:SUWARNO
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 1:1100 OLIVE WAY
Mailing Address - Street 2:M4-PFS
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1873
Mailing Address - Country:US
Mailing Address - Phone:206-515-5811
Mailing Address - Fax:
Practice Address - Street 1:1100 9TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2756
Practice Address - Country:US
Practice Address - Phone:206-223-2319
Practice Address - Fax:360-756-6666
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004525363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1093771537OtherMONTANA DSHS
WA8372674Medicaid
P45402Medicare UPIN
WA8372674Medicaid