Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 6077-015 | WI |
NPI | 1114143534 |
---|---|
Provider Name | Regan Frederick Brown |
First Address | Woodbury, MN 55125-3414 |
Second Address | New Richmond, WI 54017-2565 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/04/2007 |
Last Update Date | 13/06/2011 |