Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | 20239 | WI |
NPI | 1487753406 |
---|---|
Provider Name | Marshall Edward Cusic JR. |
First Address | Marshfield, WI 54449-5703 |
Second Address | Marshfield, WI 54449-5703 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
30405200 | (05) | WI |
A92018 | (02) |