Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207X00000X | Orthopaedic Surgeon | G61231 | CA |
NPI | 1003126830 |
---|---|
Provider Name | Grietje Van Dyk |
First Address | Los Alamitos, CA 90720-3353 |
Second Address | Los Alamitos, CA 90720-3353 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/10/2010 |
Last Update Date | 27/10/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
F53209 | (02) | CA |