Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 0101-047216 | VA |
N | 208000000X | Pediatrician | 29353 | NC |
Y | 2080P0214X | Pediatric Pulmonologist | 0101-047216 | VA |
N | 2080P0214X | Pediatric Pulmonologist | 29353 | NC |
NPI | 1255303525 |
---|---|
Provider Name | Andre Muelenaer JR. |
First Address | Roanoke, VA 24013-2256 |
Second Address | Roanoke, VA 24013-2256 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/02/2006 |
Last Update Date | 30/04/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
6747680 | (05) | VA |
C85666 | (02) | VA |