Provider Demographics
NPI:1306597414
Name:CARBALLO, DAPHNE (PA-C)
Entity type:Individual
Prefix:
First Name:DAPHNE
Middle Name:
Last Name:CARBALLO
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 1:11902 93RD LN NE APT 102
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3651
Mailing Address - Country:US
Mailing Address - Phone:786-512-4050
Mailing Address - Fax:
Practice Address - Street 1:2320 W COMMODORE WAY UNIT 100
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98199-1287
Practice Address - Country:US
Practice Address - Phone:206-632-4575
Practice Address - Fax:206-632-4576
Is Sole Proprietor?:No
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61190261363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical