Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1043651912 |
---|---|
Provider Name | Isaac Mardis |
First Address | Fallon, NV 89407-1240 |
Second Address | Fallon, NV 89406-3103 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/07/2013 |
Last Update Date | 08/07/2013 |