Basic Information
| Provider Information | |||||||||
| NPI: | 1467543355 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOULEK | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | J | ||||||||
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| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FERRIS | ||||||||
| OtherFirstName: | SANDRA | ||||||||
| OtherMiddleName: | JEAN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3900 S ZINTEL WAY | ||||||||
| Address2: | |||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099423627 | ||||||||
| FaxNumber: | 5099422268 | ||||||||
| Practice Location | |||||||||
| Address1: | 560 GAGE BLVD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099423135 | ||||||||
| FaxNumber: | 5096271188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 09/27/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA10004233 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 0242335 | 01 | WA | LABOR & INDUSTRIES | OTHER | 1467543355 | 05 | WA | MEDICAID |