MEDICARE: SUSAN ANNE KAISAKI P.A.-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA10003830	WA

General Provider Information

NPI Number	:	1629126842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN ANNE KAISAKI P.A.-C

Provider Business Mailing Address
First Line	:	8500 MAIN ST UNIT F211
Second Line	:
City	:	EDMONDS
State	:	WA
Zip	:	98026-6954
Country	:	US
Telephone Number	:	425-770-4775
Fax Number	:

Provider Business Practice Location Address
First Line	:	1212 HARRISON AVE NW
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98502-5466
Country	:	US
Telephone Number	:	360-754-6700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2007
Last Update Date	:	07/08/2007

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