Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204E00000X | Oral & Maxillofacial Surgeon | MD00029527 | WA |
Y | 207Y00000X | Otolaryngologist (ENT Doctor) | MD00029527 | WA |
NPI | 1467445494 |
---|---|
Provider Name | Thomas Logan Stackhouse |
First Address | Bellingham, WA 98225-1892 |
Second Address | Bellingham, WA 98225-1892 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/08/2005 |
Last Update Date | 05/04/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8137978 | (05) | WA |
F26965 | (02) | WA |