Provider Demographics
NPI:1700830155
Name:BUUM, ROBERTA A (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:A
Last Name:BUUM
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 1:1806 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2473
Mailing Address - Country:US
Mailing Address - Phone:509-452-4520
Mailing Address - Fax:509-452-5224
Practice Address - Street 1:521 E MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-3865
Practice Address - Country:US
Practice Address - Phone:509-962-1414
Practice Address - Fax:509-962-1408
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003677363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7118250Medicaid
WA0226463OtherL&I
WA0226463OtherL&I
WAAB38059Medicare Oscar/Certification