Provider Demographics
NPI:1568526507
Name:SHORT, MARTHA L (PA-C)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:L
Last Name:SHORT
Suffix:
Gender:F
Credentials:PA-C
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 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:550 17TH AVE
Practice Address - Street 2:STE 500
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-5788
Practice Address - Country:US
Practice Address - Phone:206-320-2800
Practice Address - Fax:206-320-2827
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004271363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0201547OtherLABOR AND INDUSTRIES
WA84323790Medicaid
WA84323790Medicaid
WA8857028Medicare ID - Type Unspecified