Basic Information
Provider Information | |||||||||
NPI: | 1073522587 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VAN FOSSEN | ||||||||
FirstName: | BRENDA | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 500 | ||||||||
Address2: |   | ||||||||
City: | ELLICOTTVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 147310500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7166999032 | ||||||||
FaxNumber: | 7166999035 | ||||||||
Practice Location | |||||||||
Address1: | 7375 OSWEGO RD | ||||||||
Address2: |   | ||||||||
City: | LIVERPOOL | ||||||||
State: | NY | ||||||||
PostalCode: | 130903717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3152910064 | ||||||||
FaxNumber: | 3152910065 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2006 | ||||||||
LastUpdateDate: | 03/22/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD00043720 | WA | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | 291334 | NY | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 0191866 | 01 | WA | STATE L&I | OTHER | 8409245 | 05 | WA |   | MEDICAID | 8939525 | 01 | WA | STATE CRIME VICTIMS | OTHER |