Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | 28242 | WI |
Y | 207ND0101X | MOHS-Micrographic Surgeon | 28242 | WI |
NPI | 1063406965 |
---|---|
Provider Name | Douglas B Horan |
First Address | Menasha, WI 54952-1165 |
Second Address | Menasha, WI 54952-1165 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/09/2005 |
Last Update Date | 01/10/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
30798400 | (05) | WI |
B84933 | (02) |