Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 2922 | NM |
NPI | 1003176660 |
---|---|
Provider Name | Mr. John L Carnagey |
First Address | Socorro, NM 87801-4626 |
Second Address | Socorro, NM 87801-4269 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/05/2012 |
Last Update Date | 16/05/2012 |