Healthcare Provider Details

I. General information

NPI: 1194115618
Provider Name (Legal Business Name): RYAN CHARLES HUOTARI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2015
Last Update Date: 02/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25115 143RD ST SE
MONROE WA
98272-9579
US

IV. Provider business mailing address

19916 OLD OWEN RD # 155
MONROE WA
98272-9778
US

V. Phone/Fax

Practice location:
  • Phone: 425-308-7422
  • Fax: 360-805-9835
Mailing address:
  • Phone: 425-308-7422
  • Fax: 360-805-9835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number602426041
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: