Provider Demographics
NPI:1225566672
Name:LOOMIS, DONOVAN PAUL (LMT)
Entity Type:Individual
Prefix:
First Name:DONOVAN
Middle Name:PAUL
Last Name:LOOMIS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14912 N PARK AVE N
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-6521
Mailing Address - Country:US
Mailing Address - Phone:206-291-3149
Mailing Address - Fax:
Practice Address - Street 1:3601 FREMONT AVE N STE 412
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-8753
Practice Address - Country:US
Practice Address - Phone:206-853-1540
Practice Address - Fax:206-853-1540
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60732442225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60732442OtherDEPARTMENT OF HEALTH