Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 175L00000X | Homeopath | D0049 | AZ |
NPI | 1053712059 |
---|---|
Provider Name | Garry Gordon |
First Address | Payson, AZ 85541 |
Second Address | Payson, AZ 85541 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/09/2014 |
Last Update Date | 09/09/2014 |