Healthcare Provider Details

I. General information

NPI: 1538227046
Provider Name (Legal Business Name): GENE BRYANT TROBAUGH MD FACC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 05/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1427 JEFFERSON AVE SUITE 202
ENUMCLAW WA
98022-3649
US

IV. Provider business mailing address

1427 JEFFERSON AVE SUITE 202
ENUMCLAW WA
98022-3649
US

V. Phone/Fax

Practice location:
  • Phone: 360-802-5021
  • Fax: 360-825-5265
Mailing address:
  • Phone: 360-802-5021
  • Fax: 360-825-5265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD00013271
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1107465
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: