Provider Demographics
NPI:1578863700
Name:WALL, BRYAN (BC-HIS)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:WALL
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26916 NE 434TH ST
Mailing Address - Street 2:
Mailing Address - City:AMBOY
Mailing Address - State:WA
Mailing Address - Zip Code:98601-4636
Mailing Address - Country:US
Mailing Address - Phone:360-247-6590
Mailing Address - Fax:
Practice Address - Street 1:15518 NE FARGHER LAKE HWY
Practice Address - Street 2:
Practice Address - City:YACOLT
Practice Address - State:WA
Practice Address - Zip Code:98675-4508
Practice Address - Country:US
Practice Address - Phone:360-263-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHA 00004733237700000X
ORHAS-P-509154237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALNI 254658OtherSATET OF WASHINGTON L&I PROVIDER