Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | 58623 | CA |
NPI | 1043844046 |
---|---|
Provider Name | Corbin Bird |
First Address | Twentynine Palms, CA 92278 |
Second Address | Twentynine Palms, CA 92277 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/02/2020 |
Last Update Date | 16/09/2021 |