Provider Demographics
NPI:1205469871
Name:WARTELLA, GARY JAMES II (LMT)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:JAMES
Last Name:WARTELLA
Suffix:II
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21201 NE 58TH ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-9660
Mailing Address - Country:US
Mailing Address - Phone:254-661-9089
Mailing Address - Fax:
Practice Address - Street 1:21201 NE 58TH ST UNIT 1
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682-9660
Practice Address - Country:US
Practice Address - Phone:254-661-9089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24737225700000X
WA60909358225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty