Provider Demographics
NPI:1992859045
Name:GREGORY, GARRY (PA-C)
Entity type:Individual
Prefix:MR
First Name:GARRY
Middle Name:
Last Name:GREGORY
Suffix:
Gender:M
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 1:3908 10TH ST SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-2188
Mailing Address - Country:US
Mailing Address - Phone:253-848-5951
Mailing Address - Fax:253-845-7073
Practice Address - Street 1:10004 204TH AVE E
Practice Address - Street 2:#1200
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-6539
Practice Address - Country:US
Practice Address - Phone:253-848-5951
Practice Address - Fax:253-845-7073
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA1000445363AM0700X, 363AS0400X
WAPA10004445363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAR23459Medicare UPIN
WAG8851981Medicare PIN