Healthcare Provider Details

I. General information

NPI: 1508643180
Provider Name (Legal Business Name): BRIAN AZAEL BACAN RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2023
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 SE NIGHTHAWK PL
SHELTON WA
98584-7602
US

IV. Provider business mailing address

221 SE NIGHTHAWK PL
SHELTON WA
98584-7602
US

V. Phone/Fax

Practice location:
  • Phone: 850-774-5850
  • Fax:
Mailing address:
  • Phone: 850-774-5850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: