Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | ABOC 11818 | NM |
NPI | 1154709749 |
---|---|
Provider Name | Mr. Paul Stevenson |
First Address | Las Cruces, NM 88001 |
Second Address | Las Cruces, NM 88001-6024 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/05/2015 |
Last Update Date | 14/05/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0183680001 | (02) | NM |