Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 268471-22 | IA |
NPI | 1003842592 |
---|---|
Provider Name | Mr. Laurie A. Siddall |
First Address | Newton, IA 50208-3155 |
Second Address | Newton, IA 50208-3155 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
S29427 | (02) | IA |