Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | OT60484207 | WA |
N | 225XH1200X | Occupational Therapist - Hand | 60484207 | WA |
NPI | 1225432354 |
---|---|
Provider Name | Mark Owen Gardner |
First Address | Spokane, WA 99220-3649 |
Second Address | Spokane, WA 99202-1426 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/10/2014 |
Last Update Date | 07/11/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
201242483WA | (05) | WA |