Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 0618003087 | VA |
NPI | 1013674597 |
---|---|
Provider Name | Jonathan Keen |
First Address | Wytheville, VA 24382-1188 |
Second Address | Wytheville, VA 24382-1188 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/11/2021 |
Last Update Date | 19/11/2021 |