Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 038013728 | IL |
NPI | 1093383994 |
---|---|
Provider Name | Dr. Tanner Joseph Wilson |
First Address | Chicago, IL 60654-4916 |
Second Address | Chicago, IL 60654-4916 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/06/2021 |
Last Update Date | 16/06/2021 |