Healthcare Provider Details

I. General information

NPI: 1568842185
Provider Name (Legal Business Name): ROSS BROCKMAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2015
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1703 S MERIDIAN STE 101
PUYALLUP WA
98371-7590
US

IV. Provider business mailing address

1200 PLEASANT ST
DES MOINES IA
50309-1406
US

V. Phone/Fax

Practice location:
  • Phone: 253-848-3000
  • Fax:
Mailing address:
  • Phone: 515-241-5008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR-10324
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberOP61156882
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: