Provider Demographics
NPI:1861927683
Name:WONGRAT-BURSON, SUREERAT (LMT)
Entity type:Individual
Prefix:
First Name:SUREERAT
Middle Name:
Last Name:WONGRAT-BURSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13320 127TH PL NE
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-5416
Mailing Address - Country:US
Mailing Address - Phone:425-802-2959
Mailing Address - Fax:
Practice Address - Street 1:515 116TH AVE NE STE 113
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-5225
Practice Address - Country:US
Practice Address - Phone:425-802-2959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-30
Last Update Date:2017-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60602293225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist