Provider Demographics
NPI:1902348709
Name:WATROBKA, MICHAEL (PAC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WATROBKA
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W IRONWOOD DR
Mailing Address - Street 2:SUITE 220 E
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2656
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 W IRONWOOD DR
Practice Address - Street 2:SUITE 120E
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2656
Practice Address - Country:US
Practice Address - Phone:208-667-9110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-09
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60753618363AM0700X
IDPA-1450363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPA-1450OtherSTATE LICENSE