Provider Demographics
NPI:1265184816
Name:BROKAW, DANIEL ROBERT (MA)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:ROBERT
Last Name:BROKAW
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1119 ELIZABETH AVE
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98337-1726
Mailing Address - Country:US
Mailing Address - Phone:651-335-7962
Mailing Address - Fax:
Practice Address - Street 1:5050 STATE HIGHWAY 303 NE STE A1
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98311-3629
Practice Address - Country:US
Practice Address - Phone:360-627-7408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60364673225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist