Provider Demographics
NPI:1073522587
Name:VAN FOSSEN, BRENDA R (MD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:R
Last Name:VAN FOSSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 500
Mailing Address - Street 2:
Mailing Address - City:ELLICOTTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14731-0500
Mailing Address - Country:US
Mailing Address - Phone:716-699-9032
Mailing Address - Fax:716-699-9035
Practice Address - Street 1:7375 OSWEGO RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-3717
Practice Address - Country:US
Practice Address - Phone:315-291-0064
Practice Address - Fax:315-291-0065
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00043720208000000X
NY291334208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0191866OtherSTATE L&I
WA8409245Medicaid
WA8939525OtherSTATE CRIME VICTIMS
WAG8850504Medicare PIN
WA8409245Medicaid