Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213E00000X | Podiatrist | ||
N | 222Z00000X | Podiatrist | ||
Y | 224P00000X | Prosthetist |
NPI | 1306387337 |
---|---|
Provider Name | Mr. John Mooney |
First Address | Glendale, WI 53209-1835 |
Second Address | Glendale, WI 53209-1835 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/03/2017 |
Last Update Date | 09/03/2017 |