Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 33655 | CA |
N | 152W00000X | Optometrist | OD60679692 | WA |
NPI | 1003269721 |
---|---|
Provider Name | Matthew Krewer |
First Address | Wenatchee, WA 98801-2028 |
Second Address | Murrieta, CA 92563-7430 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/07/2016 |
Last Update Date | 04/11/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1003269721 | (05) | WA |
P01707746 | RR PTAN WVH (01) | WA |