Provider Demographics
NPI:1508906157
Name:TETREAULT, BRIAN EDWARD (LMP)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:EDWARD
Last Name:TETREAULT
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 1:505 CEDAR AVE
Mailing Address - Street 2:SUITE C3
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-4561
Mailing Address - Country:US
Mailing Address - Phone:425-308-3390
Mailing Address - Fax:425-334-1187
Practice Address - Street 1:505 CEDAR AVE
Practice Address - Street 2:SUITE C3
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-4561
Practice Address - Country:US
Practice Address - Phone:425-308-3390
Practice Address - Fax:425-334-1187
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00007758174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist