Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TH0100X | Health Service | 00790 | IA |
NPI | 1073617676 |
---|---|
Provider Name | Amy Stockman |
First Address | Iowa City, IA 52240-3909 |
Second Address | Iowa City, IA 52240-3909 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/09/2006 |
Last Update Date | 04/02/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
01203 | WELLMARK BCBS (01) | IA |