Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | 49416 | AZ |
N | 207N00000X | Dermatologist | 50202 | CO |
N | 207N00000X | Dermatologist | MD450182 | PA |
N | 207ND0101X | MOHS-Micrographic Surgeon | 49416 | AZ |
N | 207ND0900X | Dermatopathologist | 49416 | AZ |
NPI | 1013170695 |
---|---|
Provider Name | Brendan O'neill |
First Address | Flagstaff, AZ 86001-1383 |
Second Address | Flagstaff, AZ 86001-1383 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/07/2008 |
Last Update Date | 22/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
920324 | (05) | AZ |