Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QH0002X | Family Doctor - Hospice and Palliative Medicine | A121683 | CA |
NPI | 1003044728 |
---|---|
Provider Name | Dr. Kyle P. Edmonds |
First Address | San Diego, CA 92103 |
Second Address | San Diego, CA 92103-1911 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/07/2009 |
Last Update Date | 28/02/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A121683 | STATE LICENSE (01) | CA |