Basic Information
| Provider Information | |||||||||
| NPI: | 1346575206 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARREN | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MSPAS, PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 S 320TH ST | ||||||||
| Address2: | STE A | ||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980034691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8665993376 | ||||||||
| FaxNumber: | 5033628435 | ||||||||
| Practice Location | |||||||||
| Address1: | 1730 MINOR AVE STE 1000 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981011464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062672100 | ||||||||
| FaxNumber: | 2062672100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2009 | ||||||||
| LastUpdateDate: | 01/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA60118131 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 808500600 | 05 | ID | MEDICAID |