Individual
HA TA
Active
Individual
HA TA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
0429415
KS
207R00000X
Internal Medicine Physician
Primary
MD60287362
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100400710A
—
KS
05
—
1568437069
—
WA
01
—
309609
LABOR & INDUSTRIES
WA
Enumeration date
02/20/2006
Last updated
02/13/2014
Update your record
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