Provider Demographics
NPI:1356429716
Name:CHERNEKOFF, MICHAEL LAWRENCE (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LAWRENCE
Last Name:CHERNEKOFF
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 1:2520 CHERRY AVE
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-4229
Mailing Address - Country:US
Mailing Address - Phone:360-377-3911
Mailing Address - Fax:360-377-1558
Practice Address - Street 1:1225 CAMPBELL WAY
Practice Address - Street 2:SUITE 201
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3351
Practice Address - Country:US
Practice Address - Phone:360-377-1355
Practice Address - Fax:360-377-1558
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003909363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
253470OtherINTERNAL ID-MOTOR VEHICLE ID
WA8320624Medicaid
WA8864733Medicare PIN
AB10991Medicare ID - Type Unspecified
WA8320624Medicaid