Basic Information
| Provider Information | |||||||||
| NPI: | 1245483569 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIEM | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | SHANE | ||||||||
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| Credential: | PA-C | ||||||||
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| 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: | 1035 116TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980044604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256885573 | ||||||||
| FaxNumber: | 4256885464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2008 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA60056591 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA60056591 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0377413 | 01 | WA | L&I-RADIA KING COUNTY | OTHER | 0377409 | 01 | WA | L&I-RADIA REST OF WA | OTHER | 0377427 | 01 | WA | L&I-SWEDISH RADIA EDMONDS | OTHER | 2011887 | 05 | WA | MEDICAID | 0377418 | 01 | WA | L&I-EVERGREEN RADIA | OTHER |