Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist | 86-198-10 | MO |
NPI | 1023175882 |
---|---|
Provider Name | Wray Cook |
First Address | Saint Louis, MO 63131-2321 |
Second Address | Saint Louis, MO 63131-2393 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/01/2007 |
Last Update Date | 18/03/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
321966905 | (05) | MO |