Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 54336 | TN |
N | 208000000X | Pediatrician | MD163055 | OR |
Y | 2080P0205X | Pediatric Endocrinologist | 54336 | TN |
NPI | 1174842348 |
---|---|
Provider Name | Evan Los |
First Address | Johnson City, TN 37604-6089 |
Second Address | Johnson City, TN 37604-6089 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/05/2010 |
Last Update Date | 15/02/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1174842348 | (05) | VA |
Q022585 | (05) | TN |