Provider Demographics
NPI:1598068876
Name:TROMBOLD, MARK ALAN (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:TROMBOLD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 EASTLAKE AVE E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-3728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1550 EASTLAKE AVE E
Practice Address - Street 2:SUITE 100
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-3728
Practice Address - Country:US
Practice Address - Phone:206-322-2842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00005317225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0112120OtherLABOR AND INDUSTRIES
WA5863485OtherAETNA
WATR5885OtherREGENCE