Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0100X | Occupational Health | DC006361L | PA |
NPI | 1659399715 |
---|---|
Provider Name | Lorenzo Allen Alston |
First Address | Philadelphia, PA 19103-6148 |
Second Address | Philadelphia, PA 19103-5552 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DC006361L | STATE LICENSE NUMBER (01) | PA |