Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207PE0004X | Emergency Medical Services | 00000000000 | VA |
N | 363LA2100X | Nurse Practitioner - Acute Care | 000000000000 | VA |
N | 363LC0200X | Nurse Practitioner - Critical Care Medicine | 000000000000 | VA |
Y | 363LF0000X | Nurse Practitioner - Family Medicine | APN.0997339-NP | CO |
NPI | 1154835197 |
---|---|
Provider Name | Samuel Bryan Wood |
First Address | Fort Defiance, AZ 86504-0649 |
Second Address | Fort Defiance, AZ 86504 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/11/2017 |
Last Update Date | 28/10/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00000000000 | (05) | VA |