Individual
KEITH ROBERT JEROME
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
AMBULATORY CLINIC, 825 EASTLAKE AVENUE EAST, SEATTLE, WA 98109
(206) 288-1000
Mailing address
PO BOX 50095, SEATTLE, WA 98145-5095
(206) 543-6420
Taxonomy
Speciality
Code
Description
License number
State
207ZP0105X
Clinical Pathology/Laboratory Medicine Physician
Primary
MD00036076
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0231435
L&I
WA
01
—
1322
INTERNAL ID-MOTOR VEHICLE ID
—
05
—
1386724367
—
WA
Enumeration date
10/16/2006
Last updated
02/20/2013
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