Basic Information
| Provider Information | |||||||||
| NPI: | 1770787947 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | LMP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1519 132ND ST SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982087203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253300633 | ||||||||
| FaxNumber: | 4253389637 | ||||||||
| Practice Location | |||||||||
| Address1: | 11700 MUKILTEO SPEEDWAY | ||||||||
| Address2: | SUITE 503 | ||||||||
| City: | MUKILTEO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982755432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253499692 | ||||||||
| FaxNumber: | 4253499694 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2007 | ||||||||
| LastUpdateDate: | 09/14/2007 | ||||||||
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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 | 225700000X | MA00022359 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
ID Information
| ID | Type | State | Issuer | Description | 8944930 | 01 | WA | L&I CRIME VICTIMS | OTHER | 8794WH | 01 | WA | REGENCE BS | OTHER | 2358WH | 01 | WA | REGENCE BS | OTHER | 3253WH | 01 | WA | REGENCE BS | OTHER | 9257059 | 01 | WA | AETNA/WHOLE HEALTH | OTHER | 0222411 | 01 | WA | DEPT OF L&I | OTHER |