Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207T00000X | Neurosurgeon | MD14297 | ME |
NPI | 1093724916 |
---|---|
Provider Name | James Wilson |
First Address | Scarborough, ME 04074-9701 |
Second Address | Scarborough, ME 04074-8926 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/08/2006 |
Last Update Date | 06/03/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
30009653 | (05) | NH |
301130099 | (05) | ME |
G28760 | (02) | ME |