Provider Demographics
NPI:1871650614
Name:SMITH, LENNY K (PA)
Entity Type:Individual
Prefix:
First Name:LENNY
Middle Name:K
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-3832
Mailing Address - Country:US
Mailing Address - Phone:425-261-1500
Mailing Address - Fax:
Practice Address - Street 1:2930 MAPLE ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3832
Practice Address - Country:US
Practice Address - Phone:425-261-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003247363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00734166OtherRAILROAD MEDICARE
WA8399396Medicaid
WAGAB20076Medicare PIN
WAGAB37550Medicare PIN
WAP26515Medicare UPIN
WAGAB37615Medicare PIN
WAG8872522Medicare PIN
WA8399396Medicaid
WAGAB37613Medicare PIN