Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | DO-05227 | IA |
N | 207Q00000X | Family Doctor | R10715 | IA |
N | 207QS0010X | Family Doctor - Sports Medicine | 2258 | NE |
N | 207QS0010X | Family Doctor - Sports Medicine | 94-10056 | KS |
Y | 207QS0010X | Family Doctor - Sports Medicine | DO-05227 | IA |
NPI | 1114379872 |
---|---|
Provider Name | Julia L Black |
First Address | Omaha, NE 68144-5253 |
Second Address | Omaha, NE 68144-5253 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2016 |
Last Update Date | 30/12/2020 |