Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LC0200X | Nurse Practitioner - Critical Care Medicine | 11013299 | FL |
NPI | 1508434838 |
---|---|
Provider Name | Mr. Douglas Boag |
First Address | Melbourne, FL 32935-3165 |
Second Address | Melbourne, FL 32935-3165 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2021 |
Last Update Date | 14/06/2021 |