Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RI0011X | Interventional Cardiology | 49538 | WI |
NPI | 1104836113 |
---|---|
Provider Name | Scott T Weslow |
First Address | Green Bay, WI 54303-2728 |
Second Address | Green Bay, WI 54311-6519 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/08/2006 |
Last Update Date | 26/09/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1104836113 | (05) | WI |
BW9897440 | DEA (01) |