Provider Demographics
NPI:1558325167
Name:VAN ALLEN, ERIN DOHERTY (PA-C)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:DOHERTY
Last Name:VAN ALLEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:ELIZABETH
Other - Last Name:DOHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1400 E KINCAID ST
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:1400 E KINCAID ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4127
Practice Address - Country:US
Practice Address - Phone:360-428-2586
Practice Address - Fax:360-428-6470
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004559363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1013164Medicaid
WA1013164Medicaid
WAG89010902Medicare PIN