Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 28116 | WA |
N | 207QS0010X | Family Doctor - Sports Medicine | 28116 | WA |
NPI | 1023015211 |
---|---|
Provider Name | Loren B Betteridge |
First Address | Tacoma, WA 98418-5013 |
Second Address | Tacoma, WA 98418-5013 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/07/2005 |
Last Update Date | 03/08/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1065390 | (05) | WA |
E98305 | (02) | WA |