Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | 036146849 | IL |
N | 208800000X | Urologist | 32178 | AL |
NPI | 1023308483 |
---|---|
Provider Name | Jubilee Phan |
First Address | Peoria, IL 61606-2036 |
Second Address | Peoria, IL 61606-2036 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/04/2011 |
Last Update Date | 05/10/2018 |