Basic Information
| Provider Information | |||||||||
| NPI: | 1881648475 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRAKSTAD | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | T. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 805 MADISON ST | ||||||||
| Address2: | SUITE 901 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981041172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062648100 | ||||||||
| FaxNumber: | 2062648689 | ||||||||
| Practice Location | |||||||||
| Address1: | 1560 N 115TH ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981338414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063632882 | ||||||||
| FaxNumber: | 2063634172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 10/10/2011 | ||||||||
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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 | 208600000X | MD00029189 | WA | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.