Provider Demographics
NPI:1467543355
Name:SOULEK, SANDRA J (PA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
Last Name:SOULEK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:JEAN
Other - Last Name:FERRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3900 S ZINTEL WAY
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99338
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-942-2268
Practice Address - Street 1:560 GAGE BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352
Practice Address - Country:US
Practice Address - Phone:509-942-3135
Practice Address - Fax:509-627-1188
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004233363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0242335OtherLABOR & INDUSTRIES
WA1467543355Medicaid
WA0242335OtherLABOR & INDUSTRIES
WA1467543355Medicaid
WAP49273Medicare UPIN