Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VM0101X | Gynecologist - Maternal & Fetal Medicine | 7499 | NV |
NPI | 1366520280 |
---|---|
Provider Name | Stacy Eldon Mellum |
First Address | Reno, NV 89503-4505 |
Second Address | Reno, NV 89503-4505 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/11/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
20-16628 | (05) | NV |
G07433 | (02) | NV |