Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | R208690 | MD |
NPI | 1023384963 |
---|---|
Provider Name | Mr. Sergey L Istomin |
First Address | Bethesda, MD 20814-1848 |
Second Address | Bethesda, MD 20814-1848 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/03/2012 |
Last Update Date | 03/12/2013 |