Provider Demographics
NPI:1124532502
Name:GORKOVCHENKO, ENNESSA IVY (PA-C)
Entity type:Individual
Prefix:MS
First Name:ENNESSA
Middle Name:IVY
Last Name:GORKOVCHENKO
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:PO BOX 2242
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99210-2242
Mailing Address - Country:US
Mailing Address - Phone:509-747-6194
Mailing Address - Fax:509-252-2837
Practice Address - Street 1:217 W CATALDO AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2217
Practice Address - Country:US
Practice Address - Phone:509-747-6194
Practice Address - Fax:509-252-2837
Is Sole Proprietor?:No
Enumeration Date:2017-11-21
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAPA60901681363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPA60901681OtherDEPARTMENT OF HEALTH