Provider Demographics
NPI:1114905577
Name:SHORT, VICKI L (MD)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:L
Last Name:SHORT
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 1:2075 BARKLEY BLVD # 105
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-6614
Mailing Address - Country:US
Mailing Address - Phone:360-671-3345
Mailing Address - Fax:360-650-1354
Practice Address - Street 1:2075 BARKLEY BLVD STE 105
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-6614
Practice Address - Country:US
Practice Address - Phone:360-671-3345
Practice Address - Fax:360-650-1354
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036610207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8231367Medicaid
E89174Medicare UPIN
WAAB05349Medicare ID - Type Unspecified