Healthcare Provider Details

I. General information

NPI: 1821498296
Provider Name (Legal Business Name): BRETT MATTHEW THORSTEN FLORY P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2014
Last Update Date: 06/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 176TH ST S
SPANAWAY WA
98387
US

IV. Provider business mailing address

225 176TH ST S
SPANAWAY WA
98387-9201
US

V. Phone/Fax

Practice location:
  • Phone: 253-459-7777
  • Fax:
Mailing address:
  • Phone: 253-459-7777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA186181
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60520518
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOA60534015
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: