Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0102X | Surgical Critical Care | 104094 | MO |
NPI | 1255388666 |
---|---|
Provider Name | Kevin Mitchell |
First Address | Granite Bay, CA 95746-6305 |
Second Address | Marysville, CA 95901-5668 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/05/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00G867120 | (05) | CA |
E18514 | (02) | MO |