Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | MD61136032 | WA |
NPI | 1114421344 |
---|---|
Provider Name | J K Van Etten |
First Address | Camas, WA 98607-7473 |
Second Address | Cleveland, OH 44109-1900 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/03/2018 |
Last Update Date | 21/12/2021 |