Basic Information
| Provider Information | |||||||||
| NPI: | 1558302125 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUYA | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 W 5TH | ||||||||
| Address2: | #400 WEST | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093533960 | ||||||||
| FaxNumber: | 5093430134 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 W 5TH | ||||||||
| Address2: | #400 WEST | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093533960 | ||||||||
| FaxNumber: | 5093430134 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 02/19/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1744R1102X | MD00017383 | WA | Y | Other Service Providers | Specialist | Research Study |
ID Information
| ID | Type | State | Issuer | Description | 8145203 | 05 | WA | MEDICAID | B002 | 01 | TRI CARE | OTHER | BR5756 | 01 | WA | ASURIS | OTHER | 130579 | 01 | WA | L&I | OTHER | 0024765 | 05 | MT | MEDICAID |