Healthcare Provider Details

I. General information

NPI: 1104029545
Provider Name (Legal Business Name): BONNIE SUZANNE HUBER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 02/04/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12607 SE MILL PLAIN BLVD NORTHWEST PERMANENTE
VANCOUVER WA
98684-6055
US

IV. Provider business mailing address

12607 SE MILL PLAIN BLVD NORTHWEST PERMANENTE
VANCOUVER WA
98684-6055
US

V. Phone/Fax

Practice location:
  • Phone: 360-896-4460
  • Fax: 360-896-4478
Mailing address:
  • Phone: 360-896-4460
  • Fax: 360-896-4478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD 14234
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD 60341605
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: