Provider Demographics
NPI:1316249907
Name:ASSOCIATED VALLEY PROVIDERS PLLC
Entity type:Organization
Organization Name:ASSOCIATED VALLEY PROVIDERS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-255-5111
Mailing Address - Street 1:4361 TALBOT RD S STE 112
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-6226
Mailing Address - Country:US
Mailing Address - Phone:425-255-5111
Mailing Address - Fax:425-254-0985
Practice Address - Street 1:4361 TALBOT RD S STE 112
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-6226
Practice Address - Country:US
Practice Address - Phone:425-255-5111
Practice Address - Fax:425-254-0985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032726207Q00000X
WAPO00000396213ES0103X
WAAP30004306363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7112634Medicaid
WAGAB29073Medicare UPIN
WA7112634Medicaid