Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | A160694547 | WA |
Y | 213ES0000X | Sports Medicine | A160694547 | WA |
NPI | 1023638400 |
---|---|
Provider Name | Iain Mistrot |
First Address | Bothell, WA 98011-7658 |
Second Address | Seattle, WA 98195-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/04/2020 |
Last Update Date | 25/04/2020 |