Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 4804 | IA |
NPI | 1518085745 |
---|---|
Provider Name | Dr. Gary Allen Derby |
First Address | Albia, IA 52531-2059 |
Second Address | Albia, IA 52531-2059 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/03/2007 |
Last Update Date | 08/07/2007 |