Basic Information
| Provider Information | |||||||||
| NPI: | 1548770670 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POE | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | PA-C, MPAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 209 MARTIN LUTHER KING JR WAY | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535963300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 209 M.L.K. JR WAY | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535963300 | ||||||||
| FaxNumber: | 2068770652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2017 | ||||||||
| LastUpdateDate: | 05/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 60794308 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.