Provider Demographics
NPI:1386978104
Name:HILLER, BRIAN J (PA-C)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:HILLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:853 WATSON ST N STE 201
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-9348
Mailing Address - Country:US
Mailing Address - Phone:360-768-4045
Mailing Address - Fax:360-226-3942
Practice Address - Street 1:853 WATSON ST N STE 201
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022
Practice Address - Country:US
Practice Address - Phone:360-768-4045
Practice Address - Fax:360-226-3942
Is Sole Proprietor?:No
Enumeration Date:2009-09-25
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60115653363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0254801OtherSTATE L&I
G8885218Medicare PIN