Provider Demographics
NPI:1457363657
Name:TROSTAD, JIM
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:TROSTAD
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 1:19319 7TH AVE NE STE 100
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-7442
Mailing Address - Country:US
Mailing Address - Phone:360-598-3764
Mailing Address - Fax:360-598-3282
Practice Address - Street 1:2500 CHERRY AVE STE 203
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-4202
Practice Address - Country:US
Practice Address - Phone:360-792-1015
Practice Address - Fax:360-792-0964
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002052225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8852713Medicare ID - Type Unspecified