=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548698442
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA RADOVICH PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2013
-----------------------------------------------------
Last Update Date | 03/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4455 148TH AVE NE # B1
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98007-3120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 63-862-6002
-----------------------------------------------------
Fax | 425-296-3622
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 BROADWAY FL 7
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98122-5330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-820-1221
-----------------------------------------------------
Fax | 425-821-9362
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA60421555
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------