Basic Information
| Provider Information | |||||||||
| NPI: | 1790088052 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IVANEK | ||||||||
| FirstName: | LENORA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 S J ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534266341 | ||||||||
| FaxNumber: | 2534266344 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 S J ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534266341 | ||||||||
| FaxNumber: | 2534266344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2010 | ||||||||
| LastUpdateDate: | 02/26/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA60191143 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0301161 | 01 | WA | STATE L&I | OTHER | 0274355 | 01 | WA | STATE L&I | OTHER | 0304365 | 01 | WA | STATE L&I | OTHER | 0301184 | 01 | WA | STATE L&I | OTHER | 0287539 | 01 | WA | STATE L&I | OTHER | 0287560 | 01 | WA | STATE L&I | OTHER | 0287576 | 01 | WA | STATE L&I | OTHER |