Provider Demographics
NPI:1578927935
Name:SUPERFISKY, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SUPERFISKY
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 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-543-6420
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-0001
Practice Address - Country:US
Practice Address - Phone:206-543-6420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60660939367500000X
WARN00175587163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1578927935Medicaid
WA8954324Medicare PIN