Provider Demographics
NPI:1225381130
Name:LASLEY, MICAH (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICAH
Middle Name:
Last Name:LASLEY
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 1:4029 NORTHWEST AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-9077
Mailing Address - Country:US
Mailing Address - Phone:360-752-0518
Mailing Address - Fax:
Practice Address - Street 1:4029 NORTHWEST AVE STE 301
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-9077
Practice Address - Country:US
Practice Address - Phone:360-752-0518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5224363AM0700X
WA60509731363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60509731OtherWA STATE PA LICENSE
WA60509731OtherWA STATE PA LICENSE