Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213E00000X | Podiatrist | ||
N | 222Z00000X | Podiatrist | ||
Y | 224P00000X | Prosthetist |
NPI | 1326363771 |
---|---|
Provider Name | Brandon E Dale |
First Address | Phoenix, AZ 99999-0000 |
Second Address | Phoenix, AZ 85042-9628 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/03/2010 |
Last Update Date | 29/03/2010 |