Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 0724 | AZ |
Y | 222Z00000X | Podiatrist | 0724 | AZ |
NPI | 1013216373 |
---|---|
Provider Name | Keith Thomas Bangart |
First Address | Peoria, AZ 85381-4836 |
Second Address | Peoria, AZ 85381-4836 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/03/2011 |
Last Update Date | 15/03/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0724 | LICENSE # (01) | AZ |
6647440001 | NSC PTAN (01) | AZ |
FB2444812 | DEA # (01) |