Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213EP1101X | Primary Podiatric Medicine | PO60750804 | WA |
Y | 213ES0103X | Foot & Ankle Surgery | PO60750804 | WA |
NPI | 1356758668 |
---|---|
Provider Name | Jerod Stanley |
First Address | Olympia, WA 98506-5065 |
Second Address | Olympia, WA 98506-5065 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/07/2014 |
Last Update Date | 01/04/2019 |