Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204D00000X | Neuromusculoskeletal Medicine (NMM) | AZ3125 | AZ |
N | 207Q00000X | Family Doctor | AZ03125 | AZ |
NPI | 1598862070 |
---|---|
Provider Name | David William Shoup |
First Address | Glendale, AZ 85308-6813 |
Second Address | Glendale, AZ 85308-6500 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/09/2006 |
Last Update Date | 17/02/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D03125 | (02) | AR |