Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213E00000X | Podiatrist | ||
N | 222Z00000X | Podiatrist | ||
Y | 224P00000X | Prosthetist |
NPI | 1043833619 |
---|---|
Provider Name | Tim Shride |
First Address | Kirkland, WA 98033-4756 |
Second Address | Sacramento, CA 95821-2688 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/05/2020 |
Last Update Date | 18/05/2020 |