Provider Demographics
NPI:1952319972
Name:GREATHOUSE, RAYLEEN AMY (PA-C)
Entity Type:Individual
Prefix:MS
First Name:RAYLEEN
Middle Name:AMY
Last Name:GREATHOUSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 S 500 E STE 600
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1971
Mailing Address - Country:US
Mailing Address - Phone:801-587-6336
Mailing Address - Fax:801-587-6459
Practice Address - Street 1:32018 23RD AVE S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6022
Practice Address - Country:US
Practice Address - Phone:253-839-3030
Practice Address - Fax:206-520-1799
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60271754363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0293199OtherL&I
WA1952319972Medicaid
Q66128Medicare UPIN
WA8908845Medicare PIN