Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QS0010X | Family Doctor - Sports Medicine | 036157079 | IL |
NPI | 1255866448 |
---|---|
Provider Name | Jonathan Aubry |
First Address | Urbana, IL 61801-2529 |
Second Address | Bloomington, IL 61704-8111 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/04/2017 |
Last Update Date | 17/08/2021 |