Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | 1189 | OH |
NPI | 1750327524 |
---|---|
Provider Name | Thomas Andrew Konicki |
First Address | Centerville, OH 45459-3814 |
Second Address | Centerville, OH 45459-3814 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U72502 | (02) | OH |