Provider Demographics
NPI:1164440434
Name:GRODESKY, MICHAEL J (ARNP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:GRODESKY
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24366
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-0366
Mailing Address - Country:US
Mailing Address - Phone:206-598-0502
Mailing Address - Fax:206-598-0516
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-0001
Practice Address - Country:US
Practice Address - Phone:206-598-8750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00154484163W00000X
WAAP30006742363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU56897OtherREGENCE BLUESHIELD
WA0193918OtherLABOR & INDUSTRIES
WA9644238Medicaid
WA8852723Medicare PIN
WA0193918OtherLABOR & INDUSTRIES