Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | 11-06118 | KS |
NPI | 1003474230 |
---|---|
Provider Name | Clay Andrew Mulligan |
First Address | Scott City, KS 67871-6117 |
Second Address | Scott City, KS 67871-6117 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/06/2019 |
Last Update Date | 03/06/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100091670Q | (05) | KS |