Provider Demographics
NPI:1104877976
Name:VICTOR R. MICHALAK
Entity type:Organization
Organization Name:VICTOR R. MICHALAK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:KNOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-391-2500
Mailing Address - Street 1:295 NE GILMAN BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-2906
Mailing Address - Country:US
Mailing Address - Phone:425-391-2500
Mailing Address - Fax:425-391-6464
Practice Address - Street 1:295 NE GILMAN BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027
Practice Address - Country:US
Practice Address - Phone:425-391-2500
Practice Address - Fax:425-391-6464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA50-C0001197261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB24025Medicare ID - Type Unspecified