Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | A86451 | CA |
NPI | 1699751008 |
---|---|
Provider Name | Massimo Testa |
First Address | Park City, UT 84098-7557 |
Second Address | Salt Lake City, UT 84102-2310 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/12/2005 |
Last Update Date | 20/02/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H34077 | (02) | CA |