Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | AK4179 | AK |
Y | 207ND0101X | MOHS-Micrographic Surgeon | AK4179 | AK |
N | 207ND0900X | Dermatopathologist | AK4179 | AK |
N | 207NP0225X | Pediatric Dermatologist | AK4179 | AK |
N | 207NS0135X | Procedural Dermatology | AK4179 | AK |
NPI | 1245368695 |
---|---|
Provider Name | Dr. Mathew M Cannava |
First Address | Soldotna, AK 99669-0780 |
Second Address | Soldotna, AK 99669-7540 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/02/2007 |
Last Update Date | 10/02/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H62672 | (02) | AK |
MD16711 | (05) | AK |