Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 085.007026 | IL |
NPI | 1154883593 |
---|---|
Provider Name | Kristin K. Lietzau |
First Address | Beloit, WI 53511-1842 |
Second Address | Beloit, WI 53511-1842 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/04/2019 |
Last Update Date | 28/05/2019 |