Provider Demographics
NPI:1902238553
Name:SULEJMANOVIC-BORDEAUX, IRMA (ARNP)
Entity type:Individual
Prefix:
First Name:IRMA
Middle Name:
Last Name:SULEJMANOVIC-BORDEAUX
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 1:501 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3550
Mailing Address - Country:US
Mailing Address - Phone:509-494-6700
Mailing Address - Fax:509-573-6275
Practice Address - Street 1:402 S 12TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3115
Practice Address - Country:US
Practice Address - Phone:509-575-0114
Practice Address - Fax:509-575-0808
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE111558363LP0200X
WAAP60553295363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2045286Medicaid
WA0345640OtherLABOR AND INDUSTRIES
WAG8942273Medicare PIN