Provider Demographics
NPI:1811486228
Name:IMAFIDON, GREGORY (ARNP)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:IMAFIDON
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 2ND PL N STE 11-103
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-4537
Mailing Address - Country:US
Mailing Address - Phone:425-690-3491
Mailing Address - Fax:425-690-9091
Practice Address - Street 1:521 2ND PL N STE 11-103
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-4537
Practice Address - Country:US
Practice Address - Phone:425-690-3491
Practice Address - Fax:425-690-9091
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-02
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61288019363L00000X, 363LF0000X
TXAP137759363LF0000X
TXF04180510363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF04180510OtherNP CERTIFICATION
TXAP137759OtherLICENSE