Healthcare Provider Details

I. General information

NPI: 1346575206
Provider Name (Legal Business Name): STACEY LYNN WARREN MSPAS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2009
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 MINOR AVE STE 1000
SEATTLE WA
98101-1464
US

IV. Provider business mailing address

700 S 320TH ST STE A
FEDERAL WAY WA
98003-4691
US

V. Phone/Fax

Practice location:
  • Phone: 206-267-2100
  • Fax: 206-267-2100
Mailing address:
  • Phone: 866-599-3376
  • Fax: 503-362-8435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60118131
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: