Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 650 | WI |
Y | 222Z00000X | Podiatrist | 650 | WI |
N | 213EP1101X | Primary Podiatric Medicine | 650 | WI |
NPI | 1588660609 |
---|---|
Provider Name | Paul M Jacobs |
First Address | La Crosse, WI 54601-5429 |
Second Address | La Crosse, WI 54601-5429 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/06/2005 |
Last Update Date | 22/05/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
039234217 | (02) | WI |
43212000 | (05) | WI |
T37463 | (02) |