Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | IP1801 | WV |
NPI | 1154963833 |
---|---|
Provider Name | Vivia Sequeira |
First Address | Morgantown, WV 26505 |
Second Address | Morgantown, WV 26505-2650 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/10/2019 |
Last Update Date | 14/10/2019 |