Provider Demographics
NPI:1487754503
Name:BOCKMAN, MARYANNE (PA-C)
Entity type:Individual
Prefix:
First Name:MARYANNE
Middle Name:
Last Name:BOCKMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARYANNE
Other - Middle Name:
Other - Last Name:YORKOSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-366-2983
Mailing Address - Fax:
Practice Address - Street 1:12800 BOTHELL EVERETT HWY
Practice Address - Street 2:SUITE 180
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-6642
Practice Address - Country:US
Practice Address - Phone:425-316-5130
Practice Address - Fax:425-316-5131
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003160363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7097561Medicaid
WAGAB08378Medicare PIN
WA7097561Medicaid
WAS59619Medicare UPIN