Provider Demographics
NPI:1174609879
Name:BOSH, THAYNE LYNDON (DPT)
Entity type:Individual
Prefix:DR
First Name:THAYNE
Middle Name:LYNDON
Last Name:BOSH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3992
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-3992
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9621 RIDGETOP BLVD NW
Practice Address - Street 2:SUITE #100
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8502
Practice Address - Country:US
Practice Address - Phone:360-337-7662
Practice Address - Fax:360-337-7300
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009351225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8444077Medicaid
WA9157137OtherCIGNA
WA91181639719OtherKPS
WA8444077Medicaid