Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MA60168968 | WA |
NPI | 1003197823 |
---|---|
Provider Name | Jesse Payne |
First Address | Mukilteo, WA 98275-2967 |
Second Address | Mukilteo, WA 98275-2967 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/09/2011 |
Last Update Date | 07/09/2011 |