Provider Demographics
NPI:1336339365
Name:BROCKWAY, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BROCKWAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 S 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3516
Mailing Address - Country:US
Mailing Address - Phone:509-248-8040
Mailing Address - Fax:509-248-8709
Practice Address - Street 1:313 S 9TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3516
Practice Address - Country:US
Practice Address - Phone:509-248-8040
Practice Address - Fax:509-248-8709
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOI 00000188222Z00000X
WAPS 00000189224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8418956Medicaid
WA9045675Medicaid
WA8418956Medicaid