Basic Information
| Provider Information | |||||||||
| NPI: | 1639465420 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOETAERT | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 742 LEBO BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983103325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607444950 | ||||||||
| FaxNumber: | 2535721071 | ||||||||
| Practice Location | |||||||||
| Address1: | 742 LEBO BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983103325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607444950 | ||||||||
| FaxNumber: | 2535721071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2011 | ||||||||
| LastUpdateDate: | 01/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | OP60563888 | WA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 2046384 | 05 | WA | MEDICAID |