Provider Demographics
NPI:1215382031
Name:FARRELL, ALICIA R (PA-C)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:R
Last Name:FARRELL
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 1:16259 SYLVESTER RD SW STE 401
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-3059
Mailing Address - Country:US
Mailing Address - Phone:206-823-1004
Mailing Address - Fax:206-309-3319
Practice Address - Street 1:16259 SYLVESTER RD SW STE 401
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-3059
Practice Address - Country:US
Practice Address - Phone:206-823-1004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-29
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058197363A00000X
PAOA003779363A00000X
WAPA60883650363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103278270Medicaid
PA571803FLTOtherMEDICARE
PA103278270Medicaid