Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1003983644 |
---|---|
Provider Name | Mr. Gerald Leon Wolf |
First Address | Mcminnville, OR 97128-9999 |
Second Address | Mcminnville, OR 97128-9999 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/11/2006 |
Last Update Date | 25/06/2008 |