Provider Demographics
NPI:1821129685
Name:PRIMAVERA, THOMAS DAVID (OT)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:DAVID
Last Name:PRIMAVERA
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 SE BAYSHORE DR. SUITE 102
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-4062
Mailing Address - Country:US
Mailing Address - Phone:360-279-8323
Mailing Address - Fax:360-279-8772
Practice Address - Street 1:785 SE BAYSHORE DR
Practice Address - Street 2:SUITE 102
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-4062
Practice Address - Country:US
Practice Address - Phone:360-279-8323
Practice Address - Fax:360-279-8772
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00000933174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0189569OtherDEPT OF LABOR & INDUSTRIE
WAG8852292Medicare PIN