Provider Demographics
NPI:1871672899
Name:PA SURGICAL SERVICES
Entity Type:Organization
Organization Name:PA SURGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:425-899-5510
Mailing Address - Street 1:PO BOX 8592
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-0592
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12303 NE 130TH LN
Practice Address - Street 2:SUITE 520
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3099
Practice Address - Country:US
Practice Address - Phone:425-899-5510
Practice Address - Fax:425-899-5524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10000442363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8803428Medicare ID - Type Unspecified