Provider Demographics
NPI:1689886475
Name:KORZENIOWSKI, PAMELA J (PAC)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:J
Last Name:KORZENIOWSKI
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 500
Mailing Address - Street 2:
Mailing Address - City:TOKELAND
Mailing Address - State:WA
Mailing Address - Zip Code:98590-0500
Mailing Address - Country:US
Mailing Address - Phone:360-267-0119
Mailing Address - Fax:360-267-0417
Practice Address - Street 1:2373 OLD TOKELAND RD
Practice Address - Street 2:
Practice Address - City:TOKELAND
Practice Address - State:WA
Practice Address - Zip Code:98590
Practice Address - Country:US
Practice Address - Phone:360-267-0119
Practice Address - Fax:360-267-0417
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004708363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8426595Medicaid
WA8856688Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUMBE
WAQ54415Medicare UPIN