Provider Demographics
NPI:1710173703
Name:YAKIMA VALLEY DERMATOLOGY INC. , PS
Entity Type:Organization
Organization Name:YAKIMA VALLEY DERMATOLOGY INC. , PS
Other - Org Name:VALLEY DERMATOLOGY ASSOCIATES P.S., INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:BRASWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-966-7899
Mailing Address - Street 1:3911 CASTLEVALE RD STE 301
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-7807
Mailing Address - Country:US
Mailing Address - Phone:509-966-7899
Mailing Address - Fax:509-225-6811
Practice Address - Street 1:3911 CASTLEVALE RD STE 301
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-7807
Practice Address - Country:US
Practice Address - Phone:509-966-7899
Practice Address - Fax:509-225-6811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207N00000X, 207ND0101X, 207NI0002X, 207NP0225X, 207NS0135X, 363A00000X
WAPA10004546363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological ImmunologyGroup - Single Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8178956Medicaid
8856908Medicare PIN
WAG12755Medicare UPIN
WA8802050Medicare PIN