Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 2442I | AZ |
NPI | 1174832075 |
---|---|
Provider Name | Mr. John Paul Nelson |
First Address | Mesa, AZ 85206-6780 |
Second Address | Gilbert, AZ 85295-0741 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/09/2010 |
Last Update Date | 27/09/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2442I | OPTICIAN (01) | AZ |