Provider Demographics
NPI:1255000915
Name:HETTEMA, BRIANNE DARE (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIANNE
Middle Name:DARE
Last Name:HETTEMA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BRIANNE
Other - Middle Name:DARE
Other - Last Name:KERIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1662 S 55TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-1425
Mailing Address - Country:US
Mailing Address - Phone:360-981-6047
Mailing Address - Fax:
Practice Address - Street 1:9040A JACKSON AVE
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61125934363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant