Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224P00000X | Prosthetist |
NPI | 1487086195 |
---|---|
Provider Name | Ian Allan Reynolds |
First Address | Redwood City, CA 94063-3921 |
Second Address | Redwood City, CA 94063-1785 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/08/2013 |
Last Update Date | 11/08/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
C51219 | BOC CERTIFICATION NUMBER (01) | MT |