Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RG0300X | Geriatric Medicine | 24220 | AZ |
NPI | 1104850288 |
---|---|
Provider Name | Mr. Gamal Aboul-Nasr |
First Address | Mesa, AZ 85208-1154 |
Second Address | Mesa, AZ 85208-1154 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
401480 | (05) | AZ |
AZ089184D | BCBS (01) | AZ |
G31771 | (02) |