Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207SG0201X | Clinical Genetics (M.D.) | G11168 | CA |
NPI | 1568656254 |
---|---|
Provider Name | Dr. John Mann |
First Address | Fresno, CA 93720-2941 |
Second Address | Fresno, CA 93720-2941 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/09/2007 |
Last Update Date | 05/09/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G11168 | CA MEDICAL LICENSE (01) | CA |