Provider Demographics
NPI:1073985057
Name:ANTONIUS, BRYAN JAMES (RT)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:JAMES
Last Name:ANTONIUS
Suffix:
Gender:M
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10004 204TH AVE E
Mailing Address - Street 2:SUITE 2600
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-6539
Mailing Address - Country:US
Mailing Address - Phone:253-446-3983
Mailing Address - Fax:253-862-5004
Practice Address - Street 1:10004 204TH AVE E
Practice Address - Street 2:SUITE 2600
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-6539
Practice Address - Country:US
Practice Address - Phone:253-446-3983
Practice Address - Fax:253-862-5004
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-29
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WART 605844772471C3402X
AZCRT-179672471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography