Basic Information
Provider Information | |||||||||
NPI: | 1619025830 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SNELL | ||||||||
FirstName: | BRUCE | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4411 POINT FOSDICK DR NW STE 101 | ||||||||
Address2: |   | ||||||||
City: | GIG HARBOR | ||||||||
State: | WA | ||||||||
PostalCode: | 983351703 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2538517472 | ||||||||
FaxNumber: | 2538517473 | ||||||||
Practice Location | |||||||||
Address1: | 4411 POINT FOSDICK DR NW STE 101 | ||||||||
Address2: |   | ||||||||
City: | GIG HARBOR | ||||||||
State: | WA | ||||||||
PostalCode: | 983351703 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2538517472 | ||||||||
FaxNumber: | 2538517473 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/05/2007 | ||||||||
LastUpdateDate: | 04/22/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00003074 | WA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 8374456 | 05 | WA |   | MEDICAID | 121269 | 01 | WA | L&I | OTHER | 7472SN | 01 | WA | REGENCE GH | OTHER | SN5136 | 01 | WA | REGENCE TACOMA | OTHER | 650006358 | 01 | WA | RR MC | OTHER |