Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | 109299 | IA |
Y | 213ES0000X | Sports Medicine | 109299 | IA |
NPI | 1396408316 |
---|---|
Provider Name | Joshua Mackey |
First Address | Elgin, IA 52141-9662 |
Second Address | Elgin, IA 52141-9662 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/10/2021 |
Last Update Date | 17/10/2021 |