Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | DO00000500 | WA |
NPI | 1033356035 |
---|---|
Provider Name | John L Bratlie |
First Address | Wenatchee, WA 98801-2028 |
Second Address | Omak, WA 98841-9576 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/01/2009 |
Last Update Date | 23/03/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0244743 | L&I (01) | WA |