Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2086S0129X | Vascular Surgeon | 044485 | CT |
Y | 2086S0129X | Vascular Surgeon | 201525 | LA |
NPI | 1073714358 |
---|---|
Provider Name | Hernan Antonio Bazan |
First Address | New Orleans, LA 70121 |
Second Address | New Orleans, LA 07012 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/05/2007 |
Last Update Date | 27/05/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
01078003 | (05) | MS |
044485 | LICENSE (01) | CT |
1014630 | (05) | LA |
AY26291556273 | DEA (01) | CT |