Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | 01060643A | IN |
NPI | 1366411878 |
---|---|
Provider Name | Jay Prochnau |
First Address | Muncie, IN 47303-4988 |
Second Address | Lafayette, IN 47904-2164 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/03/2006 |
Last Update Date | 10/02/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000372081 | ANTHEM PROVIDER NUMBER (01) | IN |
11438471 | CAQH NUMBER (01) | IN |
200536580 | (05) | IN |
9333888 | PHCS PID NUMBER (01) | IN |
H99364 | (02) | IN |