NPIMap

Individual provider Active NPI

Ennessa Ivy Gorkovchenko, PA-C

  • Physician Assistant
  • Spokane, WA
National Provider Identifier
1124532502
Registry record updated Sep 28, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
PA60901681 Issued in WA
Practice address
217 W Cataldo Ave
Spokane, WA 99201-2217
Phone
(509) 747-6194
Fax
(509) 252-2837
NPI assigned
Nov 21, 2017
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Sep 28, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Student in an Organized Health Care Education/Training Program 390200000X
Physician Assistant 363A00000X PA60901681 WA Primary

Addresses

Primary practice location

217 W Cataldo Ave
Spokane, WA 99201-2217

Mailing address

PO Box 2242
Spokane, WA 99210-2242
Phone (509) 747-6194

Other identifiers 1

IdentifierTypeStateIssuer
PA60901681OtherWADEPARTMENT OF HEALTH

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20190103001339 WA Practitioner - Physician Assistant 5193060689 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2018
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Providence Health and Services Washington 778 clinicians

Practice addresses (Care Compare)

101 W 8TH Ave
Spokane, WA 99204-2307

1200 E Columbia Ave
Colville, WA 99114-3354
Phone (509) 684-3701

Hospital & facility affiliations

  • Prov Sacred HRT Med Ctr & Childs Hosp. Hospital, Spokane, WA, CCN 500054

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
PA60901681WAMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Providence Health & Services Washington CurrentSince Aug 8, 2022 Accepting new patients
Columbia Surgical Specialists, PS CurrentSince Oct 1, 2018 Accepting new patients
Providence Health & Services Washington CurrentSince Aug 8, 2022 Accepting new patients
Providence Health & Services - Washington Past Accepting new patients

Locations

1200 E Columbia Ave
Colville, WA 99114
Phone (509) 684-3701

217 W Cataldo Ave
Spokane, WA 99201
Phone (509) 624-2326

217 W Cataldo Ave
Fl 3
Spokane, WA 99201
Phone (509) 624-2326

Organizations & group practices 11

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 1

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1511222400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1538092800000",
    "number": "1124532502",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 2242",
            "city": "SPOKANE",
            "state": "WA",
            "postal_code": "992102242",
            "telephone_number": "509-747-6194",
            "fax_number": "509-252-2837"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "217 W CATALDO AVE",
            "city": "SPOKANE",
            "state": "WA",
            "postal_code": "992012217",
            "telephone_number": "509-747-6194",
            "fax_number": "509-252-2837"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GORKOVCHENKO",
        "first_name": "ENNESSA",
        "middle_name": "IVY",
        "name_prefix": "Ms.",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2017-11-21",
        "last_updated": "2018-09-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "WA",
            "license": "PA60901681",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DEPARTMENT OF HEALTH",
            "identifier": "PA60901681",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Spokane, WA

Sources for this page

Verify at the official NPI Registry.