Provider Demographics
NPI:1720219173
Name:DETHERAGE, MARIA LYNN (MS, RPAC)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:LYNN
Last Name:DETHERAGE
Suffix:
Gender:F
Credentials:MS, RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31675 PACIFIC HWY S
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-5407
Mailing Address - Country:US
Mailing Address - Phone:253-215-1093
Mailing Address - Fax:253-215-1094
Practice Address - Street 1:31675 PACIFIC HWY S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5407
Practice Address - Country:US
Practice Address - Phone:253-215-1093
Practice Address - Fax:253-215-1094
Is Sole Proprietor?:No
Enumeration Date:2009-08-03
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60866304363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA211807Medicaid