Provider Demographics
NPI:1265759120
Name:BROSELLE, THOMAS (CPO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:BROSELLE
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 44TH ST SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-2200
Mailing Address - Country:US
Mailing Address - Phone:425-339-2559
Mailing Address - Fax:425-339-1583
Practice Address - Street 1:800 E CHESTNUT ST
Practice Address - Street 2:SUITE 3C
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-5241
Practice Address - Country:US
Practice Address - Phone:360-734-0298
Practice Address - Fax:360-734-9679
Is Sole Proprietor?:No
Enumeration Date:2010-04-30
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOI00000090222Z00000X
WAPS00000089224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist