Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | 22015 | PR |
NPI | 1023581931 |
---|---|
Provider Name | Hildeberto Blasco |
First Address | Trujillo Alto, PR 00976 |
Second Address | Fajardo, PR 00738 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/01/2019 |
Last Update Date | 05/10/2020 |