Provider Demographics
NPI:1437648011
Name:PERESKO, GARRETT PARKER
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:PARKER
Last Name:PERESKO
Suffix:
Gender:M
Credentials:
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 1138
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:WA
Mailing Address - Zip Code:98356-0019
Mailing Address - Country:US
Mailing Address - Phone:360-496-5112
Mailing Address - Fax:
Practice Address - Street 1:531 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:WA
Practice Address - Zip Code:98356-9323
Practice Address - Country:US
Practice Address - Phone:360-496-5145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
WAPO61185768213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program