Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist |
NPI | 1013500404 |
---|---|
Provider Name | Pauline Igo |
First Address | Medford, OR 97504-7338 |
Second Address | Medford, OR 97504-7338 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/02/2021 |
Last Update Date | 16/02/2021 |