Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QS0010X | Family Doctor - Sports Medicine | MD60878010 | WA |
NPI | 1275943060 |
---|---|
Provider Name | Cory Mitchell |
First Address | Liberty Lake, WA 99019-0032 |
Second Address | Walla Walla, WA 99362 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/05/2014 |
Last Update Date | 18/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2106443 | (05) | WA |