Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 036139532 | IL |
Y | 207Q00000X | Family Doctor | 67552-20 | WI |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 036139532 | IL |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 67552-20 | WI |
NPI | 1235572991 |
---|---|
Provider Name | Lalida Chupatanakul |
First Address | Gilbert, AZ 85297-7000 |
Second Address | Gilbert, AZ 85297 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/04/2013 |
Last Update Date | 21/09/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
RES000 | (02) | IL |