Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner | 33010 | AZ |
NPI | 1033243894 |
---|---|
Provider Name | Elden Wick |
First Address | Phoenix, AZ 85008-1004 |
Second Address | Phoenix, AZ 85008-1004 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/03/2007 |
Last Update Date | 08/07/2007 |