Basic Information
| Provider Information | |||||||||
| NPI: | 1275266496 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUSH | ||||||||
| FirstName: | AMELIA | ||||||||
| MiddleName: | ROSE | ||||||||
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| OtherLastName: | EVANS | ||||||||
| OtherFirstName: | AMELIA | ||||||||
| OtherMiddleName: | ROSE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5580 NORDIC WAY | ||||||||
| Address2: | |||||||||
| City: | FERNDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982485104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603841511 | ||||||||
| FaxNumber: | 3603845758 | ||||||||
| Practice Location | |||||||||
| Address1: | 5580 NORDIC WAY | ||||||||
| Address2: | |||||||||
| City: | FERNDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982485104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603841511 | ||||||||
| FaxNumber: | 3603845758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2022 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207Q00000X | PA61344002 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.