Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | T03377 | MO |
NPI | 1013072867 |
---|---|
Provider Name | Wade Godshall |
First Address | Blue Springs, MO 64014-3957 |
Second Address | Blue Springs, MO 64014-3957 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/12/2006 |
Last Update Date | 12/02/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U68066 | (02) | MO |