MEDICARE: MR. WOLFGANG BROLLEY PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT4092	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	144371	OTHER	WA	LABOR & INDUSTRIES
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912009325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WOLFGANG BROLLEY PT

Provider Business Mailing Address
First Line	:	432 NE RAVENNA BLVD
Second Line	:	UNIT 101
City	:	SEATTLE
State	:	WA
Zip	:	98115-8448
Country	:	US
Telephone Number	:	206-524-4977
Fax Number	:	206-524-4340

Provider Business Practice Location Address
First Line	:	7900 E GREEN LAKE DR N
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98103-4800
Country	:	US
Telephone Number	:	206-985-2236
Fax Number	:	206-985-2248

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2006
Last Update Date	:	05/24/2018

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