Basic Information
| Provider Information | |||||||||
| NPI: | 1750335956 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ISLAND | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21601 76TH AVE W | ||||||||
| Address2: | |||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980267507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256404000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16251 SYLVESTER RD SW | ||||||||
| Address2: | |||||||||
| City: | BURIEN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981663017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062449970 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 06/19/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA10004903 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA10004903 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 9205IS | 01 | WA | REGENCE ID# | OTHER | 8441677 | 05 | WA | MEDICAID |