Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | MD00023497 | WA |
Y | 207XS0106X | Orthopaedic Hand Surgeon | MD00024397 | WA |
NPI | 1245205228 |
---|---|
Provider Name | David Michael Black |
First Address | Longview, WA 98632-2465 |
Second Address | Longview, WA 98632-2465 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/02/2006 |
Last Update Date | 07/04/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1014117 | (05) | WA |
178434 | (05) | OR |
A08220 | (02) |