Provider Demographics
NPI:1871114645
Name:VAN WIERINGEN, LAZIA (PA-C)
Entity type:Individual
Prefix:
First Name:LAZIA
Middle Name:
Last Name:VAN WIERINGEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 GLADSTONE ST APT 111
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98229-6226
Mailing Address - Country:US
Mailing Address - Phone:425-367-9015
Mailing Address - Fax:
Practice Address - Street 1:2320 FREEWAY DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-5445
Practice Address - Country:US
Practice Address - Phone:360-428-2550
Practice Address - Fax:360-428-6402
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-02
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA.PA.61187952363A00000X
WAPA61187952363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant