Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RG0100X | Gastroenterologist | 75068-20 | WI |
NPI | 1013390434 |
---|---|
Provider Name | Mohamed Moneeb Abdellatif Azab |
First Address | Green Bay, WI 54303-3216 |
Second Address | Green Bay, WI 54303-3216 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/07/2015 |
Last Update Date | 11/05/2021 |