Basic Information
| Provider Information | |||||||||
| NPI: | 1275589608 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERNARD | ||||||||
| FirstName: | GABRIELLE | ||||||||
| MiddleName: | DIONYSE LAUREN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BERNARD | ||||||||
| OtherFirstName: | GABRIELLE | ||||||||
| OtherMiddleName: | DIONY LAUREN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3600 LIND AVE SW | ||||||||
| Address2: | SUITE 100 ATTN CREDENTIALING | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980574970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256902715 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1205 N 10TH ST STE A | ||||||||
| Address2: | |||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980575577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256903475 | ||||||||
| FaxNumber: | 4256909475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 08/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | G85928 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD60862290 | WA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G859280 | 01 | CA | BLUE SHIELD | OTHER | 050126CG35107 | 01 | CA | VALLEY PRES TRAILBLAZER | OTHER | G85928 | 01 | CA | BLUE CROSS | OTHER | 930123114 | 01 | CA | VALLEY PRES RAILROAD | OTHER | 2106688 | 05 | WA | MEDICAID | 00G859280 | 05 | CA | MEDICAID | 00G859280 | 01 | CA | CALOPTIMA | OTHER |