Basic Information
| Provider Information | |||||||||
| NPI: | 1164440434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRODESKY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24366 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981240366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065980502 | ||||||||
| FaxNumber: | 2065980516 | ||||||||
| Practice Location | |||||||||
| Address1: | 1959 NE PACIFIC ST | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065988750 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 10/11/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN00154484 | WA | N | Nursing Service Providers | Registered Nurse | 363LA2200X | AP30006742 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | U56897 | 01 | WA | REGENCE BLUESHIELD | OTHER | 0193918 | 01 | WA | LABOR & INDUSTRIES | OTHER | 9644238 | 05 | WA | MEDICAID |