Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213E00000X | Podiatrist | OI 00000188 | WA |
N | 222Z00000X | Podiatrist | OI 00000188 | WA |
Y | 224P00000X | Prosthetist | PS 00000189 | WA |
NPI | 1336339365 |
---|---|
Provider Name | Michael Brockway |
First Address | Yakima, WA 98902-3516 |
Second Address | Yakima, WA 98902-3516 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/07/2007 |
Last Update Date | 14/03/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8418956 | (05) | WA |
9045675 | (05) | WA |