Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | R-8769 | IA |
NPI | 1104058502 |
---|---|
Provider Name | Dr. Keith Robert Wolstenholme |
First Address | Iowa City, IA 52242-1009 |
Second Address | Iowa City, IA 52242-1009 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/08/2009 |
Last Update Date | 18/08/2009 |