Provider Demographics
NPI:1427593680
Name:WETHINGTON, BROOKE ASHLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:ASHLEY
Last Name:WETHINGTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1706 WASHINGTON WAY
Mailing Address - Street 2:PO BOX 1338
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-1701
Mailing Address - Country:US
Mailing Address - Phone:360-423-0390
Mailing Address - Fax:360-423-6230
Practice Address - Street 1:22394 MIFLIN RD STE 104
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-9593
Practice Address - Country:US
Practice Address - Phone:251-318-0053
Practice Address - Fax:251-215-6731
Is Sole Proprietor?:No
Enumeration Date:2016-12-27
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8224363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPA.60855522OtherWA STATE LICENSE NUMBER
GA1136537OtherNCCPA
GA8224OtherPA LICENSE NUMBER