Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 2311 | CO |
NPI | 1134340326 |
---|---|
Provider Name | Dr. John Richard Wilson |
First Address | Boulder, CO 80304 |
Second Address | Boulder, CO 80304 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/05/2007 |
Last Update Date | 08/07/2007 |