Provider Demographics
NPI:1316157787
Name:PEA, ANISA S (DPM)
Entity type:Individual
Prefix:DR
First Name:ANISA
Middle Name:S
Last Name:PEA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:ANISTA
Other - Middle Name:
Other - Last Name:SOFTIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 E. KINCAID ST.
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:1400 E. KINCAID ST.
Practice Address - Street 2:SKAGIT REGIONAL CLINICS
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4127
Practice Address - Country:US
Practice Address - Phone:360-848-4120
Practice Address - Fax:360-424-7945
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO60088825213E00000X, 213ES0103X
ORLL16574390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA263702OtherLABOR & INDUSTRIES
WA263702OtherLABOR & INDUSTRIES