Healthcare Provider Details

I. General information

NPI: 1205166295
Provider Name (Legal Business Name): KRISTA M. TANNERY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTA MARIE LINDSTEDT

II. Dates (important events)

Enumeration Date: 01/13/2010
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 17TH AVE A FL
SEATTLE WA
98122-5788
US

IV. Provider business mailing address

PO BOX 25608
SALT LAKE CITY UT
84125-0608
US

V. Phone/Fax

Practice location:
  • Phone: 206-386-4744
  • Fax: 206-215-1135
Mailing address:
  • Phone: 206-320-4476
  • Fax: 206-568-7043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60112541
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: