Provider Demographics
NPI:1164409637
Name:FISK, GREGORY D (PAC)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:D
Last Name:FISK
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 JASMINE ST
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-9589
Mailing Address - Country:US
Mailing Address - Phone:509-826-1600
Mailing Address - Fax:509-826-3633
Practice Address - Street 1:529 JASMINE ST
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-9589
Practice Address - Country:US
Practice Address - Phone:509-826-1600
Practice Address - Fax:509-826-3633
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60149531363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA202201OtherL & Z
WA8439796Medicaid
WA202201OtherL & Z
Q53623Medicare UPIN