Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 898 | AZ |
NPI | 1295937589 |
---|---|
Provider Name | George Lynn Bardwell |
First Address | Williams, AZ 86046-2016 |
Second Address | Williams, AZ 86046-2200 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/05/2007 |
Last Update Date | 07/06/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
860363015 | FED I D # (01) | AZ |