Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2084N0400X | Neurologist | 18429 | WI |
NPI | 1003974197 |
---|---|
Provider Name | Ivan Stanko |
First Address | Marshfield, WI 54449-5703 |
Second Address | Wausau, WI 54401-4129 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/12/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
31135800 | (05) | WI |
B56827 | (02) |