Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0100X | Occupational Health | 15618 | CA |
NPI | 1699096909 |
---|---|
Provider Name | Dr. John Walter |
First Address | Roseville, CA 95678-5400 |
Second Address | Roseville, CA 95678-5400 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2010 |
Last Update Date | 21/06/2010 |