Basic Information
| Provider Information | |||||||||
| NPI: | 1598768897 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREGORY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | AARP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2116 E SECTION ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982749124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604281700 | ||||||||
| FaxNumber: | 3608484350 | ||||||||
| Practice Location | |||||||||
| Address1: | 2116 E SECTION ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982749124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604281700 | ||||||||
| FaxNumber: | 3608484350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 363L00000X | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 9616533 | 05 | WA | MEDICAID | 0174643 | 01 | WA | L&I | OTHER |