Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | DE00008741 | WA |
NPI | 1093891533 |
---|---|
Provider Name | Willie M Hardie |
First Address | Vancouver, WA 98684-0896 |
Second Address | Vancouver, WA 98684-0896 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/10/2006 |
Last Update Date | 14/09/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1002369 | (05) | WA |
2007980 | GROUP MEDICAID (01) | WA |