Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 4598 | AZ |
NPI | 1285723015 |
---|---|
Provider Name | Dr. James Patrick Keleher |
First Address | Tucson, AZ 85711-1630 |
Second Address | Tucson, AZ 85711-2505 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/10/2006 |
Last Update Date | 18/06/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
AZ0234480 | BLUECROSS/BLUESHIELD (01) | AZ |
WC28100310 | WORKERSCOMPENSATION (01) | AZ |