Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | A76427 | CA |
NPI | 1184681298 |
---|---|
Provider Name | Jack Leroy Stclair |
First Address | Sonora, CA 95370-4264 |
Second Address | Sonora, CA 95370-8858 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/05/2006 |
Last Update Date | 08/07/2007 |