Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RR0500X | Rheumatology | 20752 | WI |
NPI | 1104822113 |
---|---|
Provider Name | Jack M Lockhart |
First Address | La Crosse, WI 54601-5429 |
Second Address | Onalaska, WI 54650-8447 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/06/2005 |
Last Update Date | 26/09/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
31317600 | (05) | WI |
B54644 | (02) |