Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213EP1101X | Primary Podiatric Medicine | 909 | WI |
NPI | 1528006863 |
---|---|
Provider Name | Holley Willenberg Tolat |
First Address | Waukesha, WI 53186-1303 |
Second Address | Waukesha, WI 53186-1303 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/06/2006 |
Last Update Date | 26/10/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
43241100 | (05) | WI |
V08870 | (02) |