Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207K00000X | Allergist & Immunologist | G21931 | CA |
NPI | 1104882729 |
---|---|
Provider Name | Bruce M Prenner |
First Address | Skyland, NC 28776-2305 |
Second Address | San Diego, CA 92108-1633 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/04/2006 |
Last Update Date | 10/11/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00G219310 | (05) | CA |
GW214Z | MEDICARE PTAN (01) | CA |