Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224P00000X | Prosthetist |
NPI | 1134110893 |
---|---|
Provider Name | Roberta J Peregrine |
First Address | Saint Joseph, MO 64506-2847 |
Second Address | Saint Joseph, MO 64506-2840 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/11/2005 |
Last Update Date | 18/03/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
27826022 | BLUECROSSBLUESHIELD (01) | MO |