NPIMap

Individual provider Active NPI

Kent William Wallace, PA-C, ARNP

  • Surgical Physician Assistant
  • Everett, WA
National Provider Identifier
1770662835
Registry record updated Feb 6, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Surgical Physician AssistantTaxonomy code 363AS0400X
License
PA10000442 Issued in WA
Practice address
1321 Colby Ave
Medical Staff Office (PMG)
Everett, WA 98201-1665
Phone
(425) 261-2000
NPI assigned
Nov 2, 2006
Last updated
Feb 6, 2015By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Feb 6, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Surgical Physician Assistant 363AS0400X PA10000442 WA Primary

Addresses

Primary practice location

1321 Colby Ave
Medical Staff Office (PMG)
Everett, WA 98201-1665

Mailing address

PO Box 3360
Providence Health & Services
Portland, OR 97208-3360
Phone (866) 366-2983

Other identifiers 3

IdentifierTypeStateIssuer
124775OtherWALABOR AND INDUSTRIES
8803430OtherWARAILROAD MEDICARE
WA6512OtherWAREGENCE

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
442WAMDFoot & Ankle Surgery Podiatrist

Practice roles

OrganizationSpecialtyStatusNew patients
Proliance Surgeons Inc P S Surgical Past Accepting new patients
Eastside Vascular LLP Past Accepting new patients
Pacific Gynecology Specialists, PC Past Accepting new patients
Institute for Laparoscopic Surgery PLLC Past Accepting new patients
Pacific Gynecology Specialists, PC Past Accepting new patients
A Womens Clinic at Evergreen PLLC PastSince Jan 1, 2003 Accepting new patients
Washington Orthopedics and Sports Medicine, PC Past Accepting new patients
Public Hospital District 1 of King County Past Accepting new patients
PA Surgical Services Surgical Past Accepting new patients
Bruce a Rolfe, MD Past Accepting new patients
Stanley a. Kopp, M.D., P.S. Past Accepting new patients
Lake Washington Vascular PLLC PastSince Oct 1, 2000 Accepting new patients

Organizations & group practices 12

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1162425600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1423180800000",
    "number": "1770662835",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3360",
            "address_2": "PROVIDENCE HEALTH & SERVICES",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972083360",
            "telephone_number": "866-366-2983"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1321 COLBY AVE",
            "address_2": "MEDICAL STAFF OFFICE (PMG)",
            "city": "EVERETT",
            "state": "WA",
            "postal_code": "982011665",
            "telephone_number": "425-261-2000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "KENT",
        "middle_name": "WILLIAM",
        "credential": "PA-C, ARNP",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-11-02",
        "last_updated": "2015-02-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AS0400X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Surgical",
            "state": "WA",
            "license": "PA10000442",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LABOR AND INDUSTRIES",
            "identifier": "124775",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "8803430",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "REGENCE",
            "identifier": "WA6512",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Everett, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 6, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.