Provider Demographics
NPI:1497424782
Name:DOROW, GREGORY CLARK (ATC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:CLARK
Last Name:DOROW
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4455 INTERLAKE AVE N UNIT 133
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-7570
Mailing Address - Country:US
Mailing Address - Phone:763-237-4228
Mailing Address - Fax:
Practice Address - Street 1:4400 INTERLAKE AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-7519
Practice Address - Country:US
Practice Address - Phone:763-237-4228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA609891592255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3059OtherMN ATC LICENSE
WA60989159OtherWA ATHLETIC TRAINER LICENSE