Provider Demographics
NPI:1174555932
Name:WAMBACH, GRETCHEN T (PA-C)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:T
Last Name:WAMBACH
Suffix:
Gender:F
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 1:565 EUREKA WAY
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-5074
Mailing Address - Country:US
Mailing Address - Phone:360-582-0808
Mailing Address - Fax:
Practice Address - Street 1:565 EUREKA WAY
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-5074
Practice Address - Country:US
Practice Address - Phone:360-582-0808
Practice Address - Fax:360-683-5678
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004382363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8358285Medicaid
WA6999WAOtherREGENCE
WA80001669803OtherKPS
WAAB38563OtherMEDICARE ID
WA800016698OtherPREMERA BLUE CROSS
WA8358285Medicaid
WA800016698OtherPREMERA BLUE CROSS