Provider Demographics
NPI:1164823282
Name:VASICEK, TERESA E (PA-C)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:E
Last Name:VASICEK
Suffix:
Gender:F
Credentials:PA-C
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 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:1101 MADISON ST
Practice Address - Street 2:STE 1400
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-4308
Practice Address - Country:US
Practice Address - Phone:206-386-6266
Practice Address - Fax:206-386-2844
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60535275363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2042600Medicaid