Healthcare Provider Details

I. General information

NPI: 1619799962
Provider Name (Legal Business Name): TIMOTHY BRUHN EMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12207 LAKE JOSEPHINE BLVD
ANDERSON ISLAND WA
98303-8709
US

IV. Provider business mailing address

9521 124TH AVE
ANDERSON ISLAND WA
98303-9713
US

V. Phone/Fax

Practice location:
  • Phone: 360-348-3732
  • Fax:
Mailing address:
  • Phone: 360-348-3732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number5526-6562-7034
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: