Provider Demographics
NPI:1043304363
Name:BRINK, LEANNE (PA)
Entity type:Individual
Prefix:
First Name:LEANNE
Middle Name:
Last Name:BRINK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S 336TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6328
Mailing Address - Country:US
Mailing Address - Phone:253-838-6180
Mailing Address - Fax:253-838-6418
Practice Address - Street 1:330 S STILLAGUAMISH AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-1642
Practice Address - Country:US
Practice Address - Phone:360-435-2133
Practice Address - Fax:360-435-1415
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004914363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8440091Medicaid
WA3085BROtherBSWA
WA605960011OtherFBL
WA0227576OtherLIWA
WA0216271OtherLIWA
WA8440091Medicaid
WAG8869699Medicare PIN
WA0216271OtherLIWA