Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224P00000X | Prosthetist |
NPI | 1053993618 |
---|---|
Provider Name | Mr. Russell Rodolfo De Palma |
First Address | Santa Fe, NM 87505-4781 |
Second Address | Albuquerque, NM 87106-5214 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/04/2021 |
Last Update Date | 23/04/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
CP003517 | AMERICAN BOARD FOR CERTIFICATION (01) | VA |