Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | 25566-21 | WI |
N | 2081P2900X | Pain Medicine | 25566 | WI |
NPI | 1174636898 |
---|---|
Provider Name | Lester Owens |
First Address | Wausau, WI 54401-2950 |
Second Address | Wausau, WI 54401-2950 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/08/2006 |
Last Update Date | 17/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
30019100 | (05) | WI |
AO7279450 | DEA# (01) | WI |
B55553 | (02) | WI |