Provider Demographics
NPI:1700424959
Name:ANDAHAZY, REBECCA SHANNON (PA-C)
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:SHANNON
Last Name:ANDAHAZY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:SHANNON
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 6116
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98064-6116
Mailing Address - Country:US
Mailing Address - Phone:425-291-3300
Mailing Address - Fax:425-291-5300
Practice Address - Street 1:18012 68TH AVE S STE 101
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-1022
Practice Address - Country:US
Practice Address - Phone:425-291-3300
Practice Address - Fax:425-291-5300
Is Sole Proprietor?:No
Enumeration Date:2019-12-18
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61581825363AM0700X
KS15-02567363A00000X
ALPA.1551363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPA61581825OtherPHYSICIAN ASSISTANT
KS15-02567OtherKANSAS LICENSE