Provider Demographics
NPI:1730430380
Name:LYSTAD, ERIN M (PA-C)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:M
Last Name:LYSTAD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2302 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-2714
Mailing Address - Country:US
Mailing Address - Phone:206-571-6897
Mailing Address - Fax:
Practice Address - Street 1:916 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4147
Practice Address - Country:US
Practice Address - Phone:425-404-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-23
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58323363A00000X
WAPA60310348363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0303950OtherL&I
WA1730430380Medicaid
CA58323OtherMEDICAL LICENSE
WAPA60310348OtherMEDICAL LICENSE