Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 3836 | AZ |
NPI | 1982127072 |
---|---|
Provider Name | Roy Doyle Wilkins |
First Address | Lakeside, AZ 85929-6994 |
Second Address | Lakeside, AZ 85929-6994 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/07/2017 |
Last Update Date | 20/07/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DC3836 | CASH (01) | AZ |