Basic Information
| Provider Information | |||||||||
| NPI: | 1043456684 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODGERS | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 LIND AVE SW | ||||||||
| Address2: | SUITE 100 ATTN CREDENTIALING | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256902715 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 24920 104TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | KENT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256903420 | ||||||||
| FaxNumber: | 4256909420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2009 | ||||||||
| LastUpdateDate: | 03/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA60570863 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA60570863 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | G8963551 | 01 | WA | MEDICARE | OTHER | 2049501 | 05 | WA | MEDICAID |