Provider Demographics
NPI:1548851645
Name:STOUT, BRIAN MATTHEW
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:MATTHEW
Last Name:STOUT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18306 71ST AVE E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98375-1843
Mailing Address - Country:US
Mailing Address - Phone:931-538-2387
Mailing Address - Fax:
Practice Address - Street 1:18306 71ST AVE E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-1843
Practice Address - Country:US
Practice Address - Phone:931-538-2387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP60534434164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse