Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NI0013X | Independent Medical Examiner | 5678-12 | WI |
NPI | 1144997412 |
---|---|
Provider Name | Dr. Daytona Sterling Crebo |
First Address | Middleton, WI 53562-3691 |
Second Address | Middleton, WI 53562-3691 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/08/2021 |
Last Update Date | 25/08/2021 |