Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207K00000X | Allergist & Immunologist | 11594 | MT |
N | 207K00000X | Allergist & Immunologist | D0062345 | MD |
NPI | 1073605200 |
---|---|
Provider Name | Dr. Carl Edward Thornblade |
First Address | Missoula, MT 59808-1745 |
Second Address | Missoula, MT 59808-1745 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/09/2006 |
Last Update Date | 31/07/2015 |