Provider Demographics
NPI:1295408136
Name:BROSE, MARK (HIS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BROSE
Suffix:
Gender:M
Credentials:HIS
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 1713
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WA
Mailing Address - Zip Code:98354-1713
Mailing Address - Country:US
Mailing Address - Phone:360-286-6204
Mailing Address - Fax:
Practice Address - Street 1:415 118TH AVE E UNIT B
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98372-1288
Practice Address - Country:US
Practice Address - Phone:360-286-6048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60305726237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist