Provider Demographics
NPI:1346575206
Name:WARREN, STACEY LYNN (MSPAS, PA-C)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:LYNN
Last Name:WARREN
Suffix:
Gender:F
Credentials:MSPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S 320TH ST
Mailing Address - Street 2:STE A
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-4691
Mailing Address - Country:US
Mailing Address - Phone:866-599-3376
Mailing Address - Fax:503-362-8435
Practice Address - Street 1:1730 MINOR AVE STE 1000
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1464
Practice Address - Country:US
Practice Address - Phone:206-267-2100
Practice Address - Fax:206-267-2100
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-12
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60118131363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808500600Medicaid