Provider Demographics
NPI:1710908264
Name:LANDEL, GRACE P (PA-C)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:P
Last Name:LANDEL
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:PO BOX 24366
Mailing Address - Street 2:M/S 359107
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-0366
Mailing Address - Country:US
Mailing Address - Phone:206-598-8920
Mailing Address - Fax:206-598-7663
Practice Address - Street 1:4245 ROOSEVELT WAY NE
Practice Address - Street 2:BOX 354770
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-6008
Practice Address - Country:US
Practice Address - Phone:206-598-4055
Practice Address - Fax:206-598-5720
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10001588363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8356313Medicaid
WA0170441OtherLABOR AND INDUSTRY
S79728Medicare UPIN
WAAB09186Medicare PIN