Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 1509 | NC |
NPI | 1336144534 |
---|---|
Provider Name | Mark R Pustaver |
First Address | Matthews, NC 28105-3634 |
Second Address | Matthews, NC 28105-3634 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2005 |
Last Update Date | 28/06/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0872M | BLUE CROSS BLUE SHIELD (01) | NC |
5900047 | (05) | NC |
T63045 | (02) | NC |