1003823147 NPI number — MARY BETH VANBRONKHORST PA-C

Table of content: MARY BETH VANBRONKHORST PA-C (NPI 1003823147)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003823147 NPI number — MARY BETH VANBRONKHORST PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANBRONKHORST
Provider First Name:
MARY
Provider Middle Name:
BETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003823147
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
709 W ORCHARD DR
Provider Second Line Business Mailing Address:
SUITE #4
Provider Business Mailing Address City Name:
BELLINGHAM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98225-1766
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-318-8800
Provider Business Mailing Address Fax Number:
360-318-1085

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
407 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVERSON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98247-9525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-966-3441
Provider Business Practice Location Address Fax Number:
360-966-0969
Provider Enumeration Date:
08/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA10002907 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AM0700X , with the licence number: PA10002907 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8324469 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0308152 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 60332U . This is a "REGENCE BLUE SHIELD PIN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0157259 . This is a "L&I PIN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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