Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208800000X | Urologist | 57.010506 | OH |
Y | 208800000X | Urologist | MD448991 | PA |
NPI | 1053524769 |
---|---|
Provider Name | Dr. Justin Prakorb Isariyawongse |
First Address | Monroeville, PA 15146-3518 |
Second Address | Monroeville, PA 15146-3518 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/05/2007 |
Last Update Date | 10/07/2013 |