Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XL0004X | Low Vision | 011026-1 | NY |
NPI | 1275878340 |
---|---|
Provider Name | Miss Ryan Mae Peterson |
First Address | Albany, NY 12208-3410 |
Second Address | Albany, NY 12208-3410 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/11/2012 |
Last Update Date | 30/11/2012 |