Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213EP1101X | Primary Podiatric Medicine | 07001149A | IN |
N | 213EP1101X | Primary Podiatric Medicine | 794 | TN |
NPI | 1528317518 |
---|---|
Provider Name | Dr. Jerwana Laster |
First Address | Indianapolis, IN 46280-1222 |
Second Address | Indianapolis, IN 46280-1222 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/09/2012 |
Last Update Date | 12/10/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
07001149B | IN LICENSE (01) | IN |
794 | TN LICENSE (01) | TN |