Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 361 | MT |
NPI | 1518963057 |
---|---|
Provider Name | Tracy Lee Gabbert |
First Address | Glendive, MT 59330-1626 |
Second Address | Glendive, MT 59330-1626 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2005 |
Last Update Date | 27/08/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0160199 | (05) | MT |
0162929 | (05) | MT |
41410 | BC/BS OF MT (01) | MT |