Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | DC26387 | CA |
Y | 111NR0200X | Radiology | RHC147634 | CA |
Y | 213ER0200X | Radiology | RHC147634 | CA |
NPI | 1073535357 |
---|---|
Provider Name | Dr. Bruce Wayne Fissette |
First Address | Newport Beach, CA 92663-4516 |
Second Address | Westminster, CA 92683-2622 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/07/2006 |
Last Update Date | 31/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U82781 | (02) | CA |