Provider Demographics
NPI:1003823147
Name:VANBRONKHORST, MARY BETH (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:VANBRONKHORST
Suffix:
Gender:F
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 1:709 W ORCHARD DR
Mailing Address - Street 2:SUITE #4
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1766
Mailing Address - Country:US
Mailing Address - Phone:360-318-8800
Mailing Address - Fax:360-318-1085
Practice Address - Street 1:407 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EVERSON
Practice Address - State:WA
Practice Address - Zip Code:98247-9525
Practice Address - Country:US
Practice Address - Phone:360-966-3441
Practice Address - Fax:360-966-0969
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10002907363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8324469Medicaid
WA0308152OtherL&I
WA60332UOtherREGENCE BLUE SHIELD PIN
WA0157259OtherL&I PIN
WAAB27593Medicare PIN
WA0157259OtherL&I PIN
WA60332UOtherREGENCE BLUE SHIELD PIN