Basic Information
| Provider Information | |||||||||
| NPI: | 1699773549 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOX | ||||||||
| FirstName: | DANIELLE | ||||||||
| MiddleName: | BULLARD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BULLARD | ||||||||
| OtherFirstName: | DANIELLE | ||||||||
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| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 850 | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983620146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605659237 | ||||||||
| FaxNumber: | 3604571599 | ||||||||
| Practice Location | |||||||||
| Address1: | 907 GEORGIANA ST | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983623911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605650999 | ||||||||
| FaxNumber: | 3604571599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 504 | WY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 7969893-1206 | UT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA22090 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA0003481 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA60143632 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0223082 | 01 | WA | LABOR & INDUSTRIES | OTHER | 1016622 | 05 | WA | MEDICAID |