Basic Information
Provider Information | |||||||||
NPI: | 1245218429 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STORM | ||||||||
FirstName: | LYNDA | ||||||||
MiddleName: | JO | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GOLDER | ||||||||
OtherFirstName: | LYNDA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 19020 33RD AVE W STE 210 | ||||||||
Address2: |   | ||||||||
City: | LYNNWOOD | ||||||||
State: | WA | ||||||||
PostalCode: | 980364748 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4255631500 | ||||||||
FaxNumber: | 4255631374 | ||||||||
Practice Location | |||||||||
Address1: | 19020 33RD AVE W STE 210 | ||||||||
Address2: |   | ||||||||
City: | LYNNWOOD | ||||||||
State: | WA | ||||||||
PostalCode: | 980364748 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4255631500 | ||||||||
FaxNumber: | 4255631374 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/06/2006 | ||||||||
LastUpdateDate: | 10/23/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA10004574 | WA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 180728 | 01 | WA | L&I PROVIDER NUMBER | OTHER | 178162 | 01 | WA | L&I PROVIDER NUMBER | OTHER | 8377517 | 05 | WA |   | MEDICAID |