Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QS0010X | Family Doctor - Sports Medicine | 02004042A | IN |
NPI | 1235396045 |
---|---|
Provider Name | Ryan Niehaus |
First Address | Bloomington, IN 47402-1329 |
Second Address | Bloomington, IN 47401-5588 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/05/2008 |
Last Update Date | 18/12/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
201074530 | (05) | IN |