Provider Demographics
NPI:1467635201
Name:WARHOLA, MARC-GREGORY (PA-C)
Entity Type:Individual
Prefix:
First Name:MARC-GREGORY
Middle Name:
Last Name:WARHOLA
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:MADIGAN ARMY MEDICAL CTR 9040 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-1100
Mailing Address - Country:US
Mailing Address - Phone:253-968-5988
Mailing Address - Fax:253-968-3278
Practice Address - Street 1:MADIGAN ARMY MEDICAL CTR 9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-1100
Practice Address - Country:US
Practice Address - Phone:253-968-5988
Practice Address - Fax:253-968-3278
Is Sole Proprietor?:No
Enumeration Date:2007-12-16
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3678363A00000X
WA60285461363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ328693Medicaid
AZZ132127Medicare PIN