Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | 070.022579 | IL |
Y | 213ES0000X | Sports Medicine | 070.022579 | IL |
NPI | 1093369589 |
---|---|
Provider Name | Jacob Canright |
First Address | Davenport, IA 52806-3059 |
Second Address | Davenport, IA 52806-3059 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/08/2019 |
Last Update Date | 01/08/2019 |