Provider Demographics
NPI:1255365219
Name:WIX, GRETCHEN PAIGE (PA-C)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:PAIGE
Last Name:WIX
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 3707
Mailing Address - Street 2:MC 61-40
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-2447
Mailing Address - Country:US
Mailing Address - Phone:425-237-3600
Mailing Address - Fax:425-965-3752
Practice Address - Street 1:800 LOGAN AVE N
Practice Address - Street 2:BUILDING 4-04, MEDICAL
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-2080
Practice Address - Country:US
Practice Address - Phone:425-237-1333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004652363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4303397Medicaid
ID806970500Medicaid
WA8390924Medicaid
AKN/AMedicaid
WA8390924Medicaid
AKN/AMedicaid