Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2251S0007X | Physical Therapist - Sports | PT24015 | CA |
Y | 2251X0800X | Physical Therapist - Orthopedic | PT24015 | CA |
NPI | 1487767653 |
---|---|
Provider Name | Edgar Nepomuceno Malbas |
First Address | Eastvale, CA 92880-1097 |
Second Address | Eastvale, CA 92880-1097 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/08/2006 |
Last Update Date | 22/08/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
OPT240150 | BLUE SHIELD (01) | CA |