Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | ML60562628 | WA |
Y | 2080P0204X | Pediatric Emergency Doctor | MD60847137 | WA |
NPI | 1194119115 |
---|---|
Provider Name | Jonathan Paul Berry |
First Address | Tacoma, WA 98405-4265 |
Second Address | Tacoma, WA 98405-4265 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/03/2015 |
Last Update Date | 18/05/2021 |