Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LW0102X | Nurse Practitioner - Women's Health | 71004092A | IN |
NPI | 1073878765 |
---|---|
Provider Name | Mary Jo Gura |
First Address | Fort Wayne, IN 46825-2387 |
Second Address | Fort Wayne, IN 46825-2387 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/07/2012 |
Last Update Date | 22/01/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
201091680 | (05) | IN |