Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | ||
N | 2251S0007X | Physical Therapist - Sports | PT60819888 | WA |
NPI | 1023524154 |
---|---|
Provider Name | Corey Michael Omalley |
First Address | Kirkland, WA 98034-7500 |
Second Address | Kirkland, WA 98034-7500 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/12/2017 |
Last Update Date | 15/07/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
PT60819888 | PT LICENSE (01) | WA |