Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | DC 006735-L | PA |
N | 111NR0400X | Rehabilitation Chiropractor | AJ 006735-L | PA |
NPI | 1366631475 |
---|---|
Provider Name | Kevin Waxter |
First Address | Saylorsburg, PA 18353-9787 |
Second Address | East Stroudsburg, PA 18301-9001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/10/2007 |
Last Update Date | 15/10/2007 |