Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | G64421 | CA |
NPI | 1003826553 |
---|---|
Provider Name | Dr. Lyman Bowen Greaves JR. |
First Address | Santa Rosa, CA 95403-1757 |
Second Address | Santa Rosa, CA 95403-1757 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/08/2006 |
Last Update Date | 02/05/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E37916 | (02) |