Healthcare Provider Details

I. General information

NPI: 1417978842
Provider Name (Legal Business Name): BRUCE R DOUGLAS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 CAMELIA ST.
ROYAL CITY WA
99357
US

IV. Provider business mailing address

820 N CHELAN AVE
WENATCHEE WA
98801-2028
US

V. Phone/Fax

Practice location:
  • Phone: 509-663-8711
  • Fax:
Mailing address:
  • Phone: 509-663-8711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10005338
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: