Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 4129 | NM |
N | 2251H1200X | Hand | 1061100674 | CA |
NPI | 1982618898 |
---|---|
Provider Name | Mr. Daniel Madison Lent Koop |
First Address | Rio Rancho, NM 87144-4719 |
Second Address | Rio Rancho, NM 87144-2100 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/07/2006 |
Last Update Date | 28/01/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4129 | PT LICENSE (01) | NM |
650001175 | MEDICARE (01) |