Provider Demographics
NPI:1609404409
Name:GUBRUD, MONTANA WYNN
Entity Type:Individual
Prefix:
First Name:MONTANA
Middle Name:WYNN
Last Name:GUBRUD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 DOCK ST UNIT 334
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-3216
Mailing Address - Country:US
Mailing Address - Phone:970-401-4070
Mailing Address - Fax:
Practice Address - Street 1:1705 DOCK ST UNIT 334
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-3216
Practice Address - Country:US
Practice Address - Phone:970-401-4070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-29
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAEMT.ES.61027626146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic