Provider Demographics
NPI:1437106622
Name:SELDERS, BRENDAN (PA)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:
Last Name:SELDERS
Suffix:
Gender:M
Credentials:PA
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 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:12728 19TH AVE SE
Practice Address - Street 2:SUITE 200
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-6526
Practice Address - Country:US
Practice Address - Phone:425-225-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004907363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8446312Medicaid
P00286191OtherRAILROAD MEDICARE
WAPA10004907OtherSTATE LICENSE NUMBER
P00286191OtherRAILROAD MEDICARE
WA8446312Medicaid