Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0210X | Pediatric Nephrologist | 47017 | WI |
NPI | 1104877521 |
---|---|
Provider Name | Dr. Ellis D Avner |
First Address | Milwaukee, WI 53226-4874 |
Second Address | Milwaukee, WI 53226-4874 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/05/2006 |
Last Update Date | 30/10/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
009906261S | HUMANA (01) | |
1104877521 | (05) | WI |
34543300 | (05) | WI |
B39974 | (02) |