Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 290946 | NY |
Y | 207QS0010X | Family Doctor - Sports Medicine | 290946 | NY |
NPI | 1205240835 |
---|---|
Provider Name | Ethan Nere Beaudett |
First Address | Rochester, NY 14627-0617 |
Second Address | Rochester, NY 14627-0617 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/06/2014 |
Last Update Date | 28/05/2020 |