Provider Demographics
NPI:1659139681
Name:FOROUTAN, PAUDRA NATHAN (LMT)
Entity Type:Individual
Prefix:
First Name:PAUDRA
Middle Name:NATHAN
Last Name:FOROUTAN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22626 NE INGLEWOOD HILL RD APT 524
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98074-5008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22626 NE INGLEWOOD HILL RD APT 524
Practice Address - Street 2:
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98074-5008
Practice Address - Country:US
Practice Address - Phone:425-765-6036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-13
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61369510225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist