Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 101637 | AK |
NPI | 1013372762 |
---|---|
Provider Name | Amber Medinas |
First Address | Wasilla, AK 99654 |
Second Address | Wasilla, AK 99654-6937 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/12/2015 |
Last Update Date | 23/12/2015 |