Provider Demographics
NPI:1790088052
Name:IVANEK, LENORA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:LENORA
Middle Name:MARIE
Last Name:IVANEK
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 1:1717 S J ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4933
Mailing Address - Country:US
Mailing Address - Phone:253-426-6341
Mailing Address - Fax:253-426-6344
Practice Address - Street 1:1717 S J ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4933
Practice Address - Country:US
Practice Address - Phone:253-426-6341
Practice Address - Fax:253-426-6344
Is Sole Proprietor?:No
Enumeration Date:2010-12-08
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60191143363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0301161OtherSTATE L&I
WA0274355OtherSTATE L&I
WA0304365OtherSTATE L&I
WA0301184OtherSTATE L&I
WA0287539OtherSTATE L&I
WA0287560OtherSTATE L&I
WA0287576OtherSTATE L&I
WA0301184OtherSTATE L&I
WA0287576OtherSTATE L&I
WA0304365OtherSTATE L&I