Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QS0010X | Family Doctor - Sports Medicine | 30866-020 | WI |
NPI | 1316981327 |
---|---|
Provider Name | Joseph Van Richards |
First Address | Superior, WI 54880-5335 |
Second Address | Superior, WI 54880-5335 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/06/2006 |
Last Update Date | 14/01/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1316981327 | (05) | WI |