Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0129X | Vascular Surgeon | 25MA07250800 | NJ |
N | 2086S0129X | Vascular Surgeon | MD427177 | PA |
NPI | 1003872474 |
---|---|
Provider Name | Gregory S Domer |
First Address | Bethlehem, PA 18015-1000 |
Second Address | Easton, PA 18045-8346 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/04/2006 |
Last Update Date | 02/04/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
101443016 0001 | (05) | PA |
H86657 | (02) | PA |