Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 2285-012 | WI |
N | 111NR0200X | Radiology | 2285-012 | WI |
N | 213ER0200X | Radiology | 2285-012 | WI |
NPI | 1063415495 |
---|---|
Provider Name | Mr. Alan Lee Jolin |
First Address | Phillips, WI 54555-1411 |
Second Address | Phillips, WI 54555-1411 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/05/2005 |
Last Update Date | 20/08/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
38941200 | (05) | WI |
470889627010 | BC/BS (01) | WI |
64748 | (02) | |
P00009301 | RAILROAD MEDICARE (01) | WI |