Facts
- Status
- A
- Credential
- DO
- Type
- Individual
- Enumeration date
- 2006-05-13
- Last updated
- 2023-03-07
Licenses
- License GA
- 56255
- License WA
- OP60931223
Location
- Practice location
- 1455 BATTERSBY AVE
- City
- ENUMCLAW WA
- Postal code
- 980223634
- Phone
- 912-350-3849
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.