Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | G75995 | CA |
Y | 207XP3100X | Pediatric Orthopaedic Surgeon | 18506 | NV |
NPI | 1104845569 |
---|---|
Provider Name | Michael Johnathon Elliott |
First Address | Reno, NV 89502-2055 |
Second Address | Reno, NV 89502-1198 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/07/2006 |
Last Update Date | 23/05/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0101233368 | VIRGINIA MEDICAL LICENSE (01) | VI |
BE9761570 | DEA NUMBER (01) | CA |