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General NPI Number Information
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NPI Number | 1073985057
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Entity Type | Individual
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Provider Name | BRYAN JAMES ANTONIUS R.T.
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Gender | Male
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Dates
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Enumeration Date | 10/29/2015
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Last Update Date | 10/29/2015
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Provider Practice Location Address
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Address Line | 10004 204TH AVE E SUITE 2600
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City | BONNEY LAKE
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State | WA
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Zip | 98391-6539
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Country | US
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Telephone | 253-446-3983
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Fax | 253-862-5004
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Provider Business Mailing Address
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Address Line | 10004 204TH AVE E SUITE 2600
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City | BONNEY LAKE
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State | WA
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Zip | 98391-6539
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Country | US
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Telephone | 253-446-3983
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Fax | 253-862-5004
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2471C3402X
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Taxonomy Name | Radiography Radiologic Technologist
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License Number | RT 60584477
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 2471C3402X
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Taxonomy Name | Radiography Radiologic Technologist
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License Number | CRT-17967
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License Number State | AZ
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