1730480153 NPI number — MRS. SANELA SAMARDZIC PA-C

Table of content: MRS. SANELA SAMARDZIC PA-C (NPI 1730480153)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730480153 NPI number — MRS. SANELA SAMARDZIC PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SAMARDZIC
Provider First Name:
SANELA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NOVAKOVIC
Provider Other First Name:
SANELA
Provider Other Middle Name:
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730480153
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
805 MADISON ST
Provider Second Line Business Mailing Address:
SUITE 901
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98104-1172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-264-8100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12911 120TH AVE NE
Provider Second Line Business Practice Location Address:
SUITE H-210
Provider Business Practice Location Address City Name:
KIRKLAND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98034-3027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-823-4000
Provider Business Practice Location Address Fax Number:
425-821-3550
Provider Enumeration Date:
11/17/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA60188654 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: PA60188654 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2011187 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: G8959157 . This is a "MEDICARE PTAN KING CO." identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: G8959158 . This is a "MEDICARE PTAN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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