Basic Information
| Provider Information | |||||||||
| NPI: | 1235299678 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SKROCH | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 S 336TH ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980036328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538386180 | ||||||||
| FaxNumber: | 2538386418 | ||||||||
| Practice Location | |||||||||
| Address1: | 21601 76TH AVENUE WEST | ||||||||
| Address2: | |||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980267507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256404000 | ||||||||
| FaxNumber: | 4256404010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 06/03/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA10003431 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0143598 | 01 | WA | LABOR AND INDUSTRIES | OTHER | 8318693 | 05 | WA | MEDICAID | 0143756 | 01 | WA | LIWA | OTHER | 0562SK | 01 | WA | BSWA | OTHER |