Provider Demographics
NPI:1629082268
Name:WESTON, BRYAN DOUGLAS (DPT)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:DOUGLAS
Last Name:WESTON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 ORCHARD ST W
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FIRCREST
Mailing Address - State:WA
Mailing Address - Zip Code:98466-6606
Mailing Address - Country:US
Mailing Address - Phone:253-564-1560
Mailing Address - Fax:253-564-4449
Practice Address - Street 1:8645 MARTIN WAY E
Practice Address - Street 2:SUITE 103
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-5851
Practice Address - Country:US
Practice Address - Phone:360-491-3900
Practice Address - Fax:360-491-3909
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00010188225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8458937Medicaid
WA8458937Medicaid