Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207T00000X | Neurosurgeon | R72004 | AZ |
NPI | 1104147909 |
---|---|
Provider Name | Karam Moon |
First Address | Phoenix, AZ 85006-2769 |
Second Address | Phoenix, AZ 85013-4409 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2010 |
Last Update Date | 28/04/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
R72004 | AZ TRAINING PERMIT (01) | AZ |