Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | DE60325350 | WA |
NPI | 1083817878 |
---|---|
Provider Name | Mr. Andrew P. Wightman |
First Address | Tocoma, WA 98409 |
Second Address | Tocoma, WA 98409 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/06/2007 |
Last Update Date | 05/12/2016 |