Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | BL01-556 | MT |
NPI | 1144609421 |
---|---|
Provider Name | Mary Shull |
First Address | Missoula, MT 59802 |
Second Address | Missoula, MT 59802-4437 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/05/2015 |
Last Update Date | 20/05/2015 |