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General NPI Number Information
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NPI Number | 1093995698
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Entity Type | Individual
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Provider Name | BRUCE A WING PA-C
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Gender | Male
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Dates
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Enumeration Date | 11/12/2007
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Last Update Date | 05/21/2018
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Provider Practice Location Address
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Address Line | 1620 COOPER POINT RD SW
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City | OLYMPIA
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State | WA
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Zip | 98502
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Country | US
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Telephone | 360-486-6710
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Fax | 360-705-0614
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Provider Business Mailing Address
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Address Line | PO BOX 3360
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City | PORTLAND
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State | OR
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Zip | 97208-3360
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Country | US
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Telephone |
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Fax |
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA 19509
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | AMD 412
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License Number State | HI
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA60705033
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License Number State | WA
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