Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 003005 | NY |
Y | 222Z00000X | Podiatrist | 003005 | NY |
NPI | 1043236391 |
---|---|
Provider Name | Greg V Wixsom |
First Address | Elmira Heights, NY 14903-1303 |
Second Address | Binghamton, NY 13905-4712 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/07/2006 |
Last Update Date | 05/09/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00577151 | (05) | NY |
T26650 | (02) | NY |