Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | 0101237249 | VA |
NPI | 1033311758 |
---|---|
Provider Name | Bryan Keenan |
First Address | San Diego, CA 92130-2387 |
Second Address | Camp Pendleton, CA 92055 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/06/2007 |
Last Update Date | 08/07/2007 |