Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 5122 | CA |
NPI | 1013078674 |
---|---|
Provider Name | Mr. Keith M. Thibault |
First Address | Oakland, CA 94611-5641 |
Second Address | Oakland, CA 94611-5641 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/12/2006 |
Last Update Date | 14/11/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
Q34820 | (02) | CA |