Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 008828 | NY |
NPI | 1023525680 |
---|---|
Provider Name | Tiffany M Wilson |
First Address | Rochester, NY 14621 |
Second Address | Rochester, NY 14621-1701 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/01/2018 |
Last Update Date | 04/01/2018 |