Basic Information
| Provider Information | |||||||||
| NPI: | 1932141389 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SURENYANTS | ||||||||
| FirstName: | IZABELLA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20200 54TH AVE W | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980366318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256726400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 20200 54TH AVE W | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980366318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256726400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 05/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA100004977 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 0218219 | 01 | WA | LIWA | OTHER | 8457723 | 05 | WA | MEDICAID | 6494SU | 01 | WA | BSWA | OTHER | 605960012 | 01 | WA | FBL | OTHER |