Healthcare Provider Details

I. General information

NPI: 1336173681
Provider Name (Legal Business Name): TROY THOMAS VANNUCCI MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 SE BISHOP BLVD SUITE 200
PULLMAN WA
99163-5502
US

IV. Provider business mailing address

840 SE BISHOP BLVD SUITE 200
PULLMAN WA
99163-5502
US

V. Phone/Fax

Practice location:
  • Phone: 509-338-9204
  • Fax: 509-338-9206
Mailing address:
  • Phone: 509-338-9204
  • Fax: 509-338-9206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00005649
License Number StateWA

VII. Legacy identifiers

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

# 1
Identifier8421869
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 2
Identifier0195911
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerDEPT LABOR & INDUSTRY
# 3
Identifier3522VA
Identifier TypeOTHER
Identifier State
Identifier IssuerASURIS NORTHWEST

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: