Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | ME0076055 | FL |
NPI | 1053306639 |
---|---|
Provider Name | Jay Conrad Beiswanger |
First Address | Panama City, FL 32405-4517 |
Second Address | Panama City, FL 32405-4517 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2005 |
Last Update Date | 31/12/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
254751100 | (05) | FL |
G87430 | (02) |