Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 40541 | NY |
NPI | 1083796759 |
---|---|
Provider Name | Mr. Gary Eugene Wilcox |
First Address | Lewiston, NY 14092 |
Second Address | Lewiston, NY 14092-1737 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/10/2006 |
Last Update Date | 08/07/2007 |