Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225C00000X | Rehabilitation Counselor | ||
Y | 363L00000X | Nurse Practitioner | 209021590 | IL |
NPI | 1225363682 |
---|---|
Provider Name | Mr. Juno Song |
First Address | Urbana, IL 61801-2529 |
Second Address | Urbana, IL 61801-2529 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/10/2009 |
Last Update Date | 31/03/2021 |