Basic Information
| Provider Information | |||||||||
| NPI: | 1346774106 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VASILAS | ||||||||
| FirstName: | GEORGIANNA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34509 9TH AVE S STE 204 | ||||||||
| Address2: | |||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980038708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5383555102 | ||||||||
| FaxNumber: | 2538355511 | ||||||||
| Practice Location | |||||||||
| Address1: | 34509 9TH AVE S STE 204 | ||||||||
| Address2: | |||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980038708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5383555102 | ||||||||
| FaxNumber: | 2538355511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2017 | ||||||||
| LastUpdateDate: | 11/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 55210 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | PA60921113 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA60921113 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2166472 | 05 | WA | MEDICAID |