Provider Demographics
NPI:1639302748
Name:ANSON, GREGORY MARK (LMP)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:MARK
Last Name:ANSON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2617 NW 64TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-2457
Mailing Address - Country:US
Mailing Address - Phone:206-399-5617
Mailing Address - Fax:
Practice Address - Street 1:1560 140TH AVE NE
Practice Address - Street 2:STE. 100
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-4571
Practice Address - Country:US
Practice Address - Phone:206-399-5617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-24
Last Update Date:2014-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60376553225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist