Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 21423456 | MN |
NPI | 1063037786 |
---|---|
Provider Name | Zoe M Little Owl |
First Address | Fargo, ND 58103-2119 |
Second Address | Fargo, ND 58103-2119 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/06/2020 |
Last Update Date | 09/06/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
555456 | (05) | MN |