Healthcare Provider Details

I. General information

NPI: 1699773549
Provider Name (Legal Business Name): DANIELLE BULLARD FOX PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DANIELLE BULLARD PA-C

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 GEORGIANA ST
PORT ANGELES WA
98362-3911
US

IV. Provider business mailing address

PO BOX 850
PORT ANGELES WA
98362-0146
US

V. Phone/Fax

Practice location:
  • Phone: 360-565-0999
  • Fax: 360-457-1599
Mailing address:
  • Phone: 360-565-9237
  • Fax: 360-457-1599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number504
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7969893-1206
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA22090
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA0003481
License Number StateCO
# 5
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60143632
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: