Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207YS0123X | Facial Plastic Surgeon | 5101018298 | MI |
Y | 207YS0123X | Facial Plastic Surgeon | 9230 | SD |
NPI | 1942437140 |
---|---|
Provider Name | Dr. Jered Marc Mancell |
First Address | Watertown, SD 57201-1548 |
Second Address | Watertown, SD 57201-1548 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2009 |
Last Update Date | 16/07/2014 |