Provider Demographics
NPI:1447257076
Name:CAPAWANA, BRADLEY JOHN (DPM)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JOHN
Last Name:CAPAWANA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:BRAD
Other - Middle Name:
Other - Last Name:CAPAWANA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:825 SE BISHOP BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5517
Mailing Address - Country:US
Mailing Address - Phone:509-334-4498
Mailing Address - Fax:509-334-0380
Practice Address - Street 1:825 SE BISHOP BLVD STE 801
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5538
Practice Address - Country:US
Practice Address - Phone:509-334-4498
Practice Address - Fax:509-339-7324
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP-159213ES0103X
WAPO00000638213ES0103X
UT953122850501213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805505000Medicaid
WA1108034Medicaid
WAGAB11014Medicare ID - Type Unspecified
ID1298150002Medicare NSC
ID1350900Medicare ID - Type Unspecified
ID805505000Medicaid