Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker |
NPI | 1003140559 |
---|---|
Provider Name | Bates Wilson |
First Address | Espanola, NM 87532-2655 |
Second Address | Espanola, NM 87532-2655 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/09/2009 |
Last Update Date | 08/10/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E7436 | (05) | NM |