Provider Demographics
NPI:1801411574
Name:JOHAL, PRABHDEEP
Entity Type:Individual
Prefix:
First Name:PRABHDEEP
Middle Name:
Last Name:JOHAL
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 1:9801 204TH AVE E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-6559
Mailing Address - Country:US
Mailing Address - Phone:253-750-8135
Mailing Address - Fax:253-750-8136
Practice Address - Street 1:32717 1ST AVE S STE 6
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5758
Practice Address - Country:US
Practice Address - Phone:253-838-5428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61071405152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist