Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 1207 | AZ |
NPI | 1003997305 |
---|---|
Provider Name | Dr. John Andrew Riley |
First Address | San Tan Valley, AZ 85143-6582 |
Second Address | Gilbert, AZ 85297-2004 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/10/2006 |
Last Update Date | 27/02/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U90500 | (02) | AZ |