Basic Information
| Provider Information | |||||||||
| NPI: | 1437524352 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAVARESKI | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 16TH AVE E | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981125226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063263000 | ||||||||
| FaxNumber: | 2063262785 | ||||||||
| Practice Location | |||||||||
| Address1: | 1330 ROCKEFELLER AVE | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982011684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253395442 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2015 | ||||||||
| LastUpdateDate: | 09/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | PA60626029 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2063236 | 05 | WA | MEDICAID |