Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 853 | NM |
N | 111NR0400X | Rehabilitation Chiropractor | 4937 | TX |
NPI | 1164573085 |
---|---|
Provider Name | Joseph Wilson |
First Address | Las Cruces, NM 88011-8682 |
Second Address | Las Cruces, NM 88011-4688 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/01/2007 |
Last Update Date | 11/08/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5677101 | AETNA (01) | TX |
603805 | BCBS OF TEXAS (01) | TX |
T41055 | (02) | TX |