Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207K00000X | Allergist & Immunologist | 10896 | AZ |
N | 207KA0200X | Allergist | 10896 | AZ |
Y | 207N00000X | Dermatologist | 10896 | AZ |
N | 207ND0101X | MOHS-Micrographic Surgeon | 10896 | AZ |
N | 207ND0900X | Dermatopathologist | 10896 | AZ |
N | 207NP0225X | Pediatric Dermatologist | 10896 | AZ |
N | 207NS0135X | Procedural Dermatology | 10896 | AZ |
NPI | 1710971320 |
---|---|
Provider Name | Bryan Robert Updegraff |
First Address | Sun City, AZ 85351-3024 |
Second Address | Sun City, AZ 85351-3024 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/09/2005 |
Last Update Date | 16/02/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D00471 | (02) | AZ |