Provider Demographics
NPI:1205162724
Name:HABERZETLE, BONNIE JEAN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:JEAN
Last Name:HABERZETLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:BONNIE
Other - Middle Name:JEAN
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5350 TALLMAN AVE NW STE 301
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-5902
Mailing Address - Country:US
Mailing Address - Phone:206-320-3335
Mailing Address - Fax:206-320-8027
Practice Address - Street 1:5350 TALLMAN AVE NW STE 301
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107
Practice Address - Country:US
Practice Address - Phone:541-515-2664
Practice Address - Fax:206-320-8027
Is Sole Proprietor?:No
Enumeration Date:2009-10-19
Last Update Date:2021-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60317981363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA258374OtherDEPARTMENT OF LABOR AND INDUSTRIES
WA8548190Medicaid
258374OtherL&I