Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 176B00000X | Midwife | 168 | AZ |
NPI | 1093050767 |
---|---|
Provider Name | Cheyanne Wilderness Gastelum |
First Address | Phoenix, AZ 85022-5836 |
Second Address | Phoenix, AZ 85022 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/12/2012 |
Last Update Date | 06/12/2012 |