Provider Demographics
NPI:1720262272
Name:BRESAW, LOIS (MD INC PS)
Entity type:Individual
Prefix:DR
First Name:LOIS
Middle Name:
Last Name:BRESAW
Suffix:
Gender:F
Credentials:MD INC PS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20700 BOND RD NE BLDG B
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-9099
Mailing Address - Country:US
Mailing Address - Phone:360-697-2199
Mailing Address - Fax:360-779-5760
Practice Address - Street 1:20700 BOND RD NE BLDG B
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-9099
Practice Address - Country:US
Practice Address - Phone:360-697-2199
Practice Address - Fax:360-779-5760
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00024914174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1130269Medicaid
WA1130269Medicaid
WA200685Medicare PIN