Provider Demographics
NPI:1033196092
Name:BROMBERG, MARK S (MSPT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:BROMBERG
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 8TH AVE NE STE 320
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029-5436
Mailing Address - Country:US
Mailing Address - Phone:425-462-5006
Mailing Address - Fax:425-462-5019
Practice Address - Street 1:3101 NORTHUP WAY STE 101
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-1435
Practice Address - Country:US
Practice Address - Phone:425-462-5006
Practice Address - Fax:425-462-5019
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007431225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1000855Medicaid
WA8347833Medicaid
WAQ20171Medicare UPIN