Provider Demographics
NPI:1356329221
Name:REZEK, NICHOLAS M (PA C)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:M
Last Name:REZEK
Suffix:
Gender:M
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 1:25246 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1252
Mailing Address - Country:US
Mailing Address - Phone:425-656-4255
Mailing Address - Fax:425-656-4003
Practice Address - Street 1:400 S 43RD ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5714
Practice Address - Country:US
Practice Address - Phone:425-228-3450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-02
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004972363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0214542OtherLIWA
WA3075REOtherBSWA
WA8442725Medicaid
WA0214542OtherLIWA