Healthcare Provider Details

I. General information

NPI: 1730782608
Provider Name (Legal Business Name): LEANN KU'UNANI IKEDA MARVIL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LEANN KU'UNANI LAZARO IKEDA PA-C

II. Dates (important events)

Enumeration Date: 11/20/2020
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 5TH ST SE STE 110
PUYALLUP WA
98374-2106
US

IV. Provider business mailing address

3801 5TH ST SE STE 110
PUYALLUP WA
98374-2106
US

V. Phone/Fax

Practice location:
  • Phone: 253-845-9585
  • Fax: 253-848-1126
Mailing address:
  • Phone: 253-845-9585
  • Fax: 253-848-1126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number61094379
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA61094379
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: