Basic Information
| Provider Information | |||||||||
| NPI: | 1356429716 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHERNEKOFF | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | LAWRENCE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2520 CHERRY AVE | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983104229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603773911 | ||||||||
| FaxNumber: | 3603771558 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 CAMPBELL WAY | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983103351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603771355 | ||||||||
| FaxNumber: | 3603771558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 01/04/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA10003909 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 253470 | 01 | INTERNAL ID-MOTOR VEHICLE ID | OTHER | 8320624 | 05 | WA | MEDICAID |