Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | 19831-20 | WI |
NPI | 1033445457 |
---|---|
Provider Name | Mr. Peter Grant Cleveland |
First Address | Baraboo, WI 53913 |
Second Address | Baraboo, WI 53913 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/10/2009 |
Last Update Date | 20/10/2009 |