Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | RT006244 | PA |
NPI | 1629456157 |
---|---|
Provider Name | Mr. Nicholas Adams |
First Address | Philadelphia, PA 19111 |
Second Address | Philadelphia, PA 19121-3302 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2015 |
Last Update Date | 11/07/2017 |