Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | D6040 | AZ |
NPI | 1023206430 |
---|---|
Provider Name | Jimmy Ray Patten |
First Address | Phoenix, AZ 85012-1839 |
Second Address | Phoenix, AZ 85012-1839 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2007 |
Last Update Date | 10/10/2007 |