Healthcare Provider Details

I. General information

NPI: 1699257824
Provider Name (Legal Business Name): SUSAN SHILAND MARVEL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10564 5TH AVE NE STE 302
SEATTLE WA
98125-7200
US

IV. Provider business mailing address

500 SW 7TH ST
RENTON WA
98057-2983
US

V. Phone/Fax

Practice location:
  • Phone: 877-522-1275
  • Fax: 509-491-3031
Mailing address:
  • Phone: 877-522-1275
  • Fax: 833-888-7145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA61012128
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: