Provider Demographics
NPI:1104193242
Name:GARRETT, LEISA S (PA-C)
Entity type:Individual
Prefix:
First Name:LEISA
Middle Name:S
Last Name:GARRETT
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 1:1201 PACIFIC AVE STE 600
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-4384
Mailing Address - Country:US
Mailing Address - Phone:253-203-3131
Mailing Address - Fax:253-397-3530
Practice Address - Street 1:1201 PACIFIC AVE STE 600
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402
Practice Address - Country:US
Practice Address - Phone:253-203-3131
Practice Address - Fax:253-397-3530
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003091363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0310585OtherSTATE L&I
WA0310585OtherSTATE L&I