Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 5279-12 | WI |
NPI | 1386170793 |
---|---|
Provider Name | Dr. Jacob William Kornetzke |
First Address | Slinger, WI 53086-9748 |
Second Address | Slinger, WI 53086-9748 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/05/2017 |
Last Update Date | 04/05/2017 |