Provider Demographics
NPI:1932141389
Name:SURENYANTS, IZABELLA
Entity Type:Individual
Prefix:
First Name:IZABELLA
Middle Name:
Last Name:SURENYANTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20200 54TH AVE W
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-6318
Mailing Address - Country:US
Mailing Address - Phone:425-672-6400
Mailing Address - Fax:
Practice Address - Street 1:20200 54TH AVE W
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-6318
Practice Address - Country:US
Practice Address - Phone:425-672-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA100004977363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0218219OtherLIWA
WA8457723Medicaid
WA6494SUOtherBSWA
WA605960012OtherFBL
WAP00396209Medicare PIN