Provider Demographics
NPI:1730782608
Name:MARVIL, LEANN KU'UNANI IKEDA (PA-C)
Entity type:Individual
Prefix:
First Name:LEANN
Middle Name:KU'UNANI IKEDA
Last Name:MARVIL
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:LEANN
Other - Middle Name:KU'UNANI LAZARO
Other - Last Name:IKEDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3801 5TH ST SE STE 110
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-2106
Mailing Address - Country:US
Mailing Address - Phone:253-845-9585
Mailing Address - Fax:253-848-1126
Practice Address - Street 1:3801 5TH ST SE STE 110
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-2106
Practice Address - Country:US
Practice Address - Phone:253-845-9585
Practice Address - Fax:253-848-1126
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61094379363AS0400X
WA61094379363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2175486Medicaid