Provider Demographics
NPI:1346774106
Name:VASILAS, GEORGIANNA NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:GEORGIANNA
Middle Name:NICOLE
Last Name:VASILAS
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 1:34509 9TH AVE S STE 204
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8708
Mailing Address - Country:US
Mailing Address - Phone:538-355-5102
Mailing Address - Fax:253-835-5511
Practice Address - Street 1:34509 9TH AVE S STE 204
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8708
Practice Address - Country:US
Practice Address - Phone:538-355-5102
Practice Address - Fax:253-835-5511
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55210363A00000X
WAPA60921113363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2166472Medicaid