Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207K00000X | Allergist & Immunologist | 31125 | AZ |
NPI | 1154312858 |
---|---|
Provider Name | Kevin M Boesel |
First Address | Peoria, AZ 85381-6097 |
Second Address | Peoria, AZ 85381-6097 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/11/2005 |
Last Update Date | 02/07/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
74965 | (02) |