Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | M-9596 | ID |
NPI | 1306832688 |
---|---|
Provider Name | Dr. Kenneth John Wakefield |
First Address | Coeur D Alene, ID 83815-9414 |
Second Address | Coeur D Alene, ID 83815-9000 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/09/2005 |
Last Update Date | 13/02/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
F71211 | (02) |