Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | CH60513691 | WA |
NPI | 1326444399 |
---|---|
Provider Name | Dr. Bradley Joseph Bodle |
First Address | Des Moines, WA 98198-6832 |
Second Address | Des Moines, WA 98198-6832 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/11/2014 |
Last Update Date | 18/11/2014 |