Provider Demographics
NPI:1487055059
Name:BRANOM, AUDREY WICKS (PA-C)
Entity type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:WICKS
Last Name:BRANOM
Suffix:
Gender:F
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 1:8810 2ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-2963
Mailing Address - Country:US
Mailing Address - Phone:360-621-5562
Mailing Address - Fax:
Practice Address - Street 1:8810 2ND AVE NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-2963
Practice Address - Country:US
Practice Address - Phone:360-621-5562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-14
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA.60595391363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant