Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 12261A | WY |
NPI | 1003278607 |
---|---|
Provider Name | Christopher Vernon Robertson |
First Address | Provo, UT 84604-3301 |
Second Address | Cody, WY 82414-9313 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/03/2016 |
Last Update Date | 14/08/2019 |