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General NPI Number Information
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NPI Number | 1427378355
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Entity Type | Organization
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Legal Business Name | MUTINY BAY MEDICAL PLLC
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Dates
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Enumeration Date | 06/02/2010
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Last Update Date | 06/02/2010
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Provider Practice Location Address
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Address Line | 5548 MYRTLE AVE STE 201
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City | FREELAND
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State | WA
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Zip | 98249-8776
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Country | US
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Telephone | 360-331-3391
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Fax |
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Provider Business Mailing Address
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Address Line | 5548 MYRTLE AVE STE 201
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City | FREELAND
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State | WA
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Zip | 98249-8776
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Country | US
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Telephone | 360-331-3391
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | THOMAS HARRIS
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Credential | DO
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Telephone | 360-331-3391
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | OP00001446
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License Number State | WA
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