Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | 252-09-0018690 | WA |
NPI | 1689758195 |
---|---|
Provider Name | Gregory Joseph Martonick |
First Address | Walla Walla, WA 99362-0351 |
Second Address | Walla Walla, WA 99362-2922 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/10/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0063736 | L & I NUMBER (01) | WA |
1300342 | (05) | WA |
A09409 | (02) | WA |