Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | 145831 | NY |
NPI | 1093885485 |
---|---|
Provider Name | Mark Smith |
First Address | New York, NY 10087-9580 |
Second Address | Brooklyn, NY 11219-2916 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/11/2006 |
Last Update Date | 11/03/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00755197 | (05) | NY |
C03681 | (02) | NY |