Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT00010706 | WA |
NPI | 1003040593 |
---|---|
Provider Name | Mr. Chi Yol Pak |
First Address | Vancouver, WA 98664-3656 |
Second Address | Vancouver, WA 98664-3656 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/05/2009 |
Last Update Date | 20/01/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4112819 | (05) | WA |