Provider Demographics
NPI:1891452322
Name:HASSARD, DUSTIN LANCE (LMT)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:LANCE
Last Name:HASSARD
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 1:4425 ISSAQUAH PINE LAKE RD SE APT G32
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98075-6249
Mailing Address - Country:US
Mailing Address - Phone:212-203-6110
Mailing Address - Fax:
Practice Address - Street 1:4425 ISSAQUAH PINE LAKE RD SE APT G32
Practice Address - Street 2:
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98075-6249
Practice Address - Country:US
Practice Address - Phone:425-659-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61080499225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist