Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224P00000X | Prosthetist | C.P., 1307 | WI |
NPI | 1134211915 |
---|---|
Provider Name | Mr. Jake Richard Wood |
First Address | Milwaukee, WI 53226 |
Second Address | Milwaukee, WI 53226 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/09/2006 |
Last Update Date | 22/08/2016 |