Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207ND0101X | MOHS-Micrographic Surgeon | A61826 | CA |
Y | 207NS0135X | Procedural Dermatology | A61826 | CA |
NPI | 1164476909 |
---|---|
Provider Name | John Barry Siebenlist |
First Address | Henderson, NV 89074-7759 |
Second Address | San Luis Obispo, CA 93401-4635 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/05/2006 |
Last Update Date | 16/03/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H14183 | (02) | CA |
P00146047 | RAILROAD MEDICARE (01) | CA |