Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | CNP-01806 | NM |
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | G081078 | IA |
NPI | 1023178548 |
---|---|
Provider Name | Mr. Dieter J Boxmann |
First Address | Waterloo, IA 50703-1901 |
Second Address | Waterloo, IA 50703-1901 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/12/2006 |
Last Update Date | 23/01/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
719261174 | (02) | IA |
Q55374 | (02) |