Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208800000X | Urologist | A93105 | CA |
N | 2088P0231X | Pediatric Urologist | 062232 | GA |
Y | 2088P0231X | Pediatric Urologist | MD 60207055 | WA |
NPI | 1013196864 |
---|---|
Provider Name | Dr. Jonathan Frank Kalisvaart |
First Address | Liberty Lake, WA 99019-0421 |
Second Address | Spokane, WA 99204-2307 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/10/2007 |
Last Update Date | 01/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
127902334A | (05) | WA |
BK9574458 | DEA (01) | WA |