Provider Demographics
NPI:1649462383
Name:GARZON ACOSTA, IRMA MELISSA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:IRMA MELISSA
Middle Name:
Last Name:GARZON ACOSTA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:IRMA
Other - Middle Name:
Other - Last Name:ACOSTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-543-6420
Mailing Address - Fax:
Practice Address - Street 1:825 EASTLAKE AVE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-4405
Practice Address - Country:US
Practice Address - Phone:206-288-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19284363A00000X
UT71184581206363AM0700X
WAPA60688495363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1649462383Medicaid
WA8958491Medicare PIN