Provider Demographics
NPI:1316957301
Name:BERTRAM, GLORIA R (ARNP)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:R
Last Name:BERTRAM
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9825
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98666-8825
Mailing Address - Country:US
Mailing Address - Phone:360-397-8024
Mailing Address - Fax:360-397-8010
Practice Address - Street 1:1601 E FOURTH PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3753
Practice Address - Country:US
Practice Address - Phone:360-397-8024
Practice Address - Fax:360-397-8010
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30000330RN00069157363L00000X, 363LA2200X, 363LF0000X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Not Answered363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Not Answered363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9604992Medicaid
WAP17181Medicare UPIN
WA9604992Medicaid