Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207L00000X | Anesthesiologist | 2017007787 | MO |
NPI | 1003252503 |
---|---|
Provider Name | Jacob Podleski |
First Address | Joplin, MO 64803-3810 |
Second Address | Joplin, MO 64804-3503 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/05/2013 |
Last Update Date | 19/07/2017 |