Healthcare Provider Details

I. General information

NPI: 1205217882
Provider Name (Legal Business Name): ISAAC-GREGORY HYDE ROBANCHO LMP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2015
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10600 NE 68TH ST STE C
KIRKLAND WA
98033-7044
US

IV. Provider business mailing address

1300 W SAM HOUSTON PKWY S STE 300
HOUSTON TX
77042-2453
US

V. Phone/Fax

Practice location:
  • Phone: 425-823-1389
  • Fax: 425-820-3996
Mailing address:
  • Phone: 425-823-1389
  • Fax: 425-820-3996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 60493092
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: