Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156F00000X | Technician/Technologist |
NPI | 1134641079 |
---|---|
Provider Name | Willie Lee Smith |
First Address | Seattle, WA 98101-2831 |
Second Address | Seattle, WA 98101-2831 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/07/2017 |
Last Update Date | 12/07/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
91-0882971 | (05) | WA |