Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | 4908-12 | WI |
NPI | 1639415698 |
---|---|
Provider Name | Andrew Charles Schupp |
First Address | Madison, WI 53704 |
Second Address | Madison, WI 53704-4610 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/12/2012 |
Last Update Date | 19/12/2012 |