Healthcare Provider Details

I. General information

NPI: 1629730502
Provider Name (Legal Business Name): LISA NICHOLE EVANOFF PA-C, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2021
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 SAND POINT WAY NE
SEATTLE WA
98105-3901
US

IV. Provider business mailing address

4800 SAND POINT WAY NE
SEATTLE WA
98105-3901
US

V. Phone/Fax

Practice location:
  • Phone: 206-987-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.PA.70094994
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDIET.DI.61590015
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: