Healthcare Provider Details

I. General information

NPI: 1427593680
Provider Name (Legal Business Name): BROOKE ASHLEY WETHINGTON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2016
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22394 MIFLIN RD STE 104
FOLEY AL
36535-9593
US

IV. Provider business mailing address

1706 WASHINGTON WAY PO BOX 1338
LONGVIEW WA
98632-1701
US

V. Phone/Fax

Practice location:
  • Phone: 251-318-0053
  • Fax: 251-215-6731
Mailing address:
  • Phone: 360-423-0390
  • Fax: 360-423-6230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8224
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: