Provider Demographics
NPI:1790195436
Name:GATZKE, JANICE M (DO)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:M
Last Name:GATZKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JANICE
Other - Middle Name:M
Other - Last Name:HILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 E. KINCAID STREET
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:
Practice Address - Street 1:1415 E KINCAID ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4126
Practice Address - Country:US
Practice Address - Phone:360-428-2501
Practice Address - Fax:360-428-2596
Is Sole Proprietor?:No
Enumeration Date:2014-05-03
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60674772207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2037598Medicaid