Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | PY00003685 | WA |
Y | 103T00000X | Psychologist | PY00003685 | WA |
NPI | 1003957291 |
---|---|
Provider Name | Dr. John Wood Fishburne IV |
First Address | Spokane, WA 99202-6204 |
Second Address | Spokane, WA 99202-6204 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/02/2007 |
Last Update Date | 08/11/2018 |