Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 175F00000X | Naturopath | ||
N | 175L00000X | Homeopath | ||
N | 225100000X | Physical Therapist | ||
N | 225400000X | Rehabilitation Practitioner |
NPI | 1700361300 |
---|---|
Provider Name | Dr. Daniel George Wilczak |
First Address | Las Cruces, NM 88001-1274 |
Second Address | Las Cruces, NM 88001-1274 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/09/2018 |
Last Update Date | 28/09/2018 |