Provider Demographics
NPI:1689601361
Name:WATERMAN, BRUCE ALLAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ALLAN
Last Name:WATERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S. 336TH ST.
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003
Mailing Address - Country:US
Mailing Address - Phone:253-838-6180
Mailing Address - Fax:
Practice Address - Street 1:NMOTC
Practice Address - Street 2:220 HOVEY RD
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32508
Practice Address - Country:US
Practice Address - Phone:850-452-9484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00037272207P00000X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG94188Medicare UPIN