Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MA60141244 | WA |
NPI | 1013270552 |
---|---|
Provider Name | Mr. Mark Anthony White JR. |
First Address | Mount Vernon, WA 98273-8968 |
Second Address | Mount Vernon, WA 98273-8968 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/06/2012 |
Last Update Date | 20/06/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
MA 60141244 | LMP, LICENSED MASSAGE PRACTICTIONER (01) | WA |