Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081P2900X | Pain Medicine | MD00014204 | WA |
NPI | 1215007091 |
---|---|
Provider Name | Dr. Joel C Konikow |
First Address | Mercer Island, WA 98040-1643 |
Second Address | Seattle, WA 98122-5229 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/11/2006 |
Last Update Date | 31/08/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2015306 | (05) | WA |
A04922 | (02) |