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NPI Code Detail

MEDICARE: LISA NICHOLE EVANOFF PA-C, RD

MEDICARE: LISA NICHOLE EVANOFF PA-C, RD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1133V00000XRegistered DietitianDIET.DI.61590015WA
2363A00000XPhysician AssistantPA.PA.70094994WA

General Provider Information

NPI Number : 1629730502
Entity Type Code : Individual
Provider Name (Legal Business Name) : LISA NICHOLE EVANOFF PA-C, RD
Provider Business Mailing Address
First Line : 4800 SAND POINT WAY NE
Second Line :
City : SEATTLE
State : WA
Zip : 98105-3901
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 4800 SAND POINT WAY NE
Second Line :
City : SEATTLE
State : WA
Zip : 98105-3901
Country : US
Telephone Number : 206-987-2000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/08/2021
Last Update Date : 03/23/2026

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