Provider Demographics
NPI:1922147016
Name:CORNS, BRUCE EDWARD (LMP)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:EDWARD
Last Name:CORNS
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4113 BRIDGEPORT WAY W STE B
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4325
Mailing Address - Country:US
Mailing Address - Phone:253-564-5828
Mailing Address - Fax:253-564-0115
Practice Address - Street 1:4113 BRIDGEPORT WAY W STE B
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4325
Practice Address - Country:US
Practice Address - Phone:253-564-5828
Practice Address - Fax:253-564-0115
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00014016174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist