Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0122X | Plastic and Reconstructive Surgery | BP10063430 | TX |
NPI | 1144717349 |
---|---|
Provider Name | Joshua Peterson |
First Address | Galveston, TX 77555-0724 |
Second Address | Galveston, TX 77555-0724 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/04/2018 |
Last Update Date | 13/04/2018 |