Provider Demographics
NPI:1568064061
Name:WASHBURN, GREG JAMES
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:JAMES
Last Name:WASHBURN
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 1:1823 N WASHINGTON ST LOT 94
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58203-1437
Mailing Address - Country:US
Mailing Address - Phone:701-330-7708
Mailing Address - Fax:
Practice Address - Street 1:1823 N WASHINGTON ST LOT 94
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58203-1437
Practice Address - Country:US
Practice Address - Phone:701-330-7708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant