Provider Demographics
NPI:1598768897
Name:GREGORY, MICHAEL A (AARP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:GREGORY
Suffix:
Gender:M
Credentials:AARP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2116 E SECTION ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-9124
Mailing Address - Country:US
Mailing Address - Phone:360-428-1700
Mailing Address - Fax:360-848-4350
Practice Address - Street 1:2116 E SECTION ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-9124
Practice Address - Country:US
Practice Address - Phone:360-428-1700
Practice Address - Fax:360-848-4350
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9616533Medicaid
WA0174643OtherL&I
WA9616533Medicaid
WA0174643OtherL&I