Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RE0101X | Endocrinologist (Diabetes Doctor) | 28060 | WI |
NPI | 1093717050 |
---|---|
Provider Name | Richard H Reynertson |
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 | 02/06/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
30769900 | (05) | WI |
B56015 | (02) |