Provider Demographics
NPI:1083012686
Name:TROUT, GARY LYLE (LMP)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LYLE
Last Name:TROUT
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16111 SE MCGILLIVRAY BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9033
Mailing Address - Country:US
Mailing Address - Phone:360-254-0994
Mailing Address - Fax:360-254-0930
Practice Address - Street 1:16111 SE MCGILLIVRAY BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-9033
Practice Address - Country:US
Practice Address - Phone:360-254-0994
Practice Address - Fax:360-254-0930
Is Sole Proprietor?:No
Enumeration Date:2014-12-12
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60496635225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist