Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 009466 | NY |
NPI | 1205296191 |
---|---|
Provider Name | Tara Swan |
First Address | Watertown, NY 13601-9407 |
Second Address | Watertown, NY 13601-9407 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/03/2016 |
Last Update Date | 04/03/2016 |