Individual
BRUCE GRAGG BLACKSTONE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
625 9TH AVE, SUITE 210, LONGVIEW, WA 98632-2465
(360) 501-3400
(360) 423-6862
Mailing address
625 9TH AVE, SUITE 210, LONGVIEW, WA 98632-2465
(360) 501-3400
(360) 423-6862
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
MD00020762
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1131101
—
WA
05
—
195560
—
OR
Enumeration date
02/20/2006
Last updated
09/22/2010
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