Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist | MD |
NPI | 1437316957 |
---|---|
Provider Name | Mrs. Renee Wagner Macsorley |
First Address | Upper Marlboro, MD 20772-3665 |
Second Address | Upper Marlboro, MD 20772-3665 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/05/2008 |
Last Update Date | 21/05/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
023053600 | (05) | DC |
30877 | KAISER PERMANENTE (01) | MD |
406540466 | MEDICARE RR (01) | DC |
468228900 | (05) | MD |
OTH000 | (02) | MD |