Healthcare Provider Details

I. General information

NPI: 1710173703
Provider Name (Legal Business Name): YAKIMA VALLEY DERMATOLOGY INC. , PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2007
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3911 CASTLEVALE RD STE 301
YAKIMA WA
98902-7807
US

IV. Provider business mailing address

3911 CASTLEVALE RD STE 301
YAKIMA WA
98902-7807
US

V. Phone/Fax

Practice location:
  • Phone: 509-966-7899
  • Fax: 509-225-6811
Mailing address:
  • Phone: 509-966-7899
  • Fax: 509-225-6811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10004546
License Number StateWA

VIII. Authorized Official

Name: HEATHER BRASWELL
Title or Position: CLINICAL MANAGER
Credential:
Phone: 509-966-7899