Provider Demographics
NPI:1790822021
Name:GEIGER, WALLACE GRANT (PAC)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:GRANT
Last Name:GEIGER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 OLIVE WAY
Mailing Address - Street 2:MS M4-PA
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1873
Mailing Address - Country:US
Mailing Address - Phone:206-515-5811
Mailing Address - Fax:206-515-5886
Practice Address - Street 1:1100 9TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2756
Practice Address - Country:US
Practice Address - Phone:206-223-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003886363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8393456Medicaid
WA0039591OtherLABOR AND INDUSTRIES#
WA5575GEOtherBLUE SHIELD #
WA5575GEOtherBLUE SHIELD #