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Individual
JACK LARRY WISDOM
Active
Individual
JACK LARRY WISDOM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CSA
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
Primary
718316
CA
163W00000X
Registered Nurse
96534
TN
Other
Enumeration date
02/21/2014
Last updated
02/21/2014
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