Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | M6663 | ID |
NPI | 1033296330 |
---|---|
Provider Name | Richard A Wathne |
First Address | Pocatello, ID 83201-2600 |
Second Address | Pocatello, ID 83201-2600 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/11/2006 |
Last Update Date | 07/09/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
F86551 | (02) | ID |