Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 8191 | AZ |
NPI | 1508239443 |
---|---|
Provider Name | John Gangemi |
First Address | Scottsdale, AZ 85266-1224 |
Second Address | Cave Creek, AZ 85331-8631 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/10/2015 |
Last Update Date | 31/10/2015 |