Provider Demographics
NPI:1114942554
Name:BROCKSMITH, DANIEL (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:BROCKSMITH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5299
Mailing Address - Street 2:MS: 315-J1-RTM
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98415-0299
Mailing Address - Country:US
Mailing Address - Phone:253-403-7537
Mailing Address - Fax:253-403-7539
Practice Address - Street 1:315 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:MS: 315-J1-TRM
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4234
Practice Address - Country:US
Practice Address - Phone:253-403-7537
Practice Address - Fax:253-403-7539
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52770363AS0400X
WAPA10004008363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8160BROtherREGENCE PIN
WA8939391OtherCRIME VICTIMS COMP PIN
WA191330OtherDEPT OF L&I PIN
WA8408346Medicaid
WA8809029Medicare PIN
WA191330OtherDEPT OF L&I PIN