Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | 000002402 | TN |
NPI | 1013944602 |
---|---|
Provider Name | Jose Villanueva |
First Address | Johnson City, TN 37604-4007 |
Second Address | Johnson City, TN 37604-4007 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0089600 | BLUE CROSS BLUE SHIELD (01) | TN |