Basic Information
| Provider Information | |||||||||
| NPI: | 1114905577 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHORT | ||||||||
| FirstName: | VICKI | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2075 BARKLEY BLVD # 105 | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982266614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606713345 | ||||||||
| FaxNumber: | 3606501354 | ||||||||
| Practice Location | |||||||||
| Address1: | 2075 BARKLEY BLVD STE 105 | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982266614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606713345 | ||||||||
| FaxNumber: | 3606501354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00036610 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8231367 | 05 | WA | MEDICAID |