Provider Demographics
NPI:1255353405
Name:BORDEAUX, ROBERT W (ARNP)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:BORDEAUX
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1633 WESTLAKE AVE N
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-6227
Mailing Address - Country:US
Mailing Address - Phone:253-344-3241
Mailing Address - Fax:877-738-7703
Practice Address - Street 1:1633 WESTLAKE AVE N
Practice Address - Street 2:SUITE 105
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-6227
Practice Address - Country:US
Practice Address - Phone:253-344-3241
Practice Address - Fax:877-738-7703
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007338363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8880928Medicare PIN
WAG8881715Medicare PIN