Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224P00000X | Prosthetist | PRO0000000083 | TN |
NPI | 1164471801 |
---|---|
Provider Name | Mr. Roger Terry Cook |
First Address | Graysville, TN 37338-4632 |
Second Address | Graysville, TN 37338-4632 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/05/2006 |
Last Update Date | 18/12/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1454290 | (05) | TN |
4067689 | BLUE CROSS BLUE SHIELD TN (01) | TN |