Provider Demographics
NPI:1124366596
Name:BACUNGAN, BRIAN B (LMP)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:B
Last Name:BACUNGAN
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 1:15433 COUNTRY CLUB DR
Mailing Address - Street 2:A103
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-1260
Mailing Address - Country:US
Mailing Address - Phone:808-232-8098
Mailing Address - Fax:
Practice Address - Street 1:2208 NW MARKET ST
Practice Address - Street 2:430B
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-4030
Practice Address - Country:US
Practice Address - Phone:808-232-8098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-19
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60320042225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist