Provider Demographics
NPI:1609956895
Name:SALLAS, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:SALLAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KENNETH
Other - Middle Name:
Other - Last Name:SALLAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:202 N DIVISION ST
Mailing Address - Street 2:PLAZA 2, SUITE 302
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98001-4939
Mailing Address - Country:US
Mailing Address - Phone:253-394-0125
Mailing Address - Fax:
Practice Address - Street 1:202 N DIVISION ST
Practice Address - Street 2:PLAZA 2, SUITE 302
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98001-4939
Practice Address - Country:US
Practice Address - Phone:253-394-0125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004745363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPA9103236OtherWASH STATE LICENSE