Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | G20818 | CA |
NPI | 1003186560 |
---|---|
Provider Name | Allen Krohn |
First Address | Redding, CA 96049-6084 |
Second Address | Redding, CA 96001-1240 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/12/2011 |
Last Update Date | 23/05/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G20818 | MEDICAL LICENSE (01) | CA |