Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225000000X | Orthotic Fitter |
NPI | 1053559310 |
---|---|
Provider Name | Marc Richard Bostian |
First Address | Oklahoma City, OK 73112-4718 |
Second Address | Oklahoma City, OK 73112-4718 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/01/2009 |
Last Update Date | 25/01/2009 |