Provider Demographics
NPI:1730480153
Name:SAMARDZIC, SANELA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SANELA
Middle Name:
Last Name:SAMARDZIC
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:SANELA
Other - Middle Name:
Other - Last Name:NOVAKOVIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:805 MADISON ST
Mailing Address - Street 2:SUITE 901
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-1172
Mailing Address - Country:US
Mailing Address - Phone:206-264-8100
Mailing Address - Fax:
Practice Address - Street 1:12911 120TH AVE NE
Practice Address - Street 2:SUITE H-210
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3027
Practice Address - Country:US
Practice Address - Phone:425-823-4000
Practice Address - Fax:425-821-3550
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60188654363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2011187Medicaid
WAG8959157OtherMEDICARE PTAN KING CO.
WAG8959158OtherMEDICARE PTAN