Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 25098.1537 | WY |
NPI | 1003360991 |
---|---|
Provider Name | Matthew Jacobson |
First Address | Torrington, WY 82440-2812 |
Second Address | Torrington, WY 82440-2812 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/08/2016 |
Last Update Date | 05/04/2019 |