Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | DO00000817 | WA |
NPI | 1073693560 |
---|---|
Provider Name | Karen Tade |
First Address | Sunnyside, WA 98944-1668 |
Second Address | Sunnyside, WA 98944-1668 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/10/2006 |
Last Update Date | 04/11/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1024454 | (05) | WA |