Provider Demographics
NPI:1619586153
Name:ETHERTON, MICHAELA (PA-S)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:ETHERTON
Suffix:
Gender:F
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 HOPYARD RD STE 410
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-3145
Mailing Address - Country:US
Mailing Address - Phone:925-251-6915
Mailing Address - Fax:
Practice Address - Street 1:915 ANDERSON DR
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-1006
Practice Address - Country:US
Practice Address - Phone:360-537-5034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2025-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAPA61229907363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program