Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | ME0080024 | FL |
NPI | 1154319689 |
---|---|
Provider Name | Walter Macedo JR. |
First Address | Lakeland, FL 33804-5004 |
Second Address | Lakeland, FL 33805 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2005 |
Last Update Date | 21/06/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
260386100 | (05) | FL |
F70024 | (02) |