Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | D86790 | MD |
NPI | 1053735365 |
---|---|
Provider Name | Mr. Ruben Troncoso JR. |
First Address | Middle River, MD 21220-2004 |
Second Address | Baltimore, MD 21287-0020 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/02/2014 |
Last Update Date | 14/09/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D86790 | MD LICENSE (01) | MD |