Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 35093592 | OH |
N | 207QS0010X | Family Doctor - Sports Medicine | 35093592 | OH |
NPI | 1225156672 |
---|---|
Provider Name | Dr. Laura M. Distel |
First Address | Wadsworth, OH 44281-8330 |
Second Address | Wadsworth, OH 44281-8330 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/03/2007 |
Last Update Date | 18/01/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3090926 | (05) | OH |