Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207YP0228X | Pediatric Otolaryngology | 23534 | AZ |
Y | 207YP0228X | Pediatric Otolaryngology | M6056 | TX |
NPI | 1023000601 |
---|---|
Provider Name | Mark Boston |
First Address | Lackland Afb, TX 78236-9907 |
Second Address | San Antonio, TX 78207-3108 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/08/2005 |
Last Update Date | 17/03/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
VAD000 | (02) |