Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156F00000X | Technician/Technologist | MA |
NPI | 1205316965 |
---|---|
Provider Name | Mr. Samuel Anthony Davis JR. |
First Address | Jamaica Plain, MA 02130 |
Second Address | Jamaica Plain, MA 02130 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/08/2018 |
Last Update Date | 21/08/2018 |