Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Y00000X | Otolaryngologist (ENT Doctor) | A114550 | CA |
NPI | 1023246089 |
---|---|
Provider Name | Anton Kushnaryov |
First Address | Santa Rosa, CA 95404-3661 |
Second Address | Santa Rosa, CA 95404-3661 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2009 |
Last Update Date | 10/07/2015 |