Provider Demographics
NPI:1932135274
Name:LOUDENBACK, DENNIS L (PAC)
Entity Type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:L
Last Name:LOUDENBACK
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7315 212TH ST SW STE 201
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7610
Mailing Address - Country:US
Mailing Address - Phone:425-778-8116
Mailing Address - Fax:425-775-9526
Practice Address - Street 1:7315 212TH ST SW
Practice Address - Street 2:SUITE 201
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7610
Practice Address - Country:US
Practice Address - Phone:425-778-8116
Practice Address - Fax:425-775-9526
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003233363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB39591Medicare ID - Type Unspecified
WAR94974Medicare UPIN