Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208G00000X | Cardiothoracic Vascular Surgeon | 01080113A | IN |
NPI | 1154616175 |
---|---|
Provider Name | Mr. Tariq Omar Lescouflair |
First Address | Fort Wayne, IN 46845-1701 |
Second Address | Fort Wayne, IN 46845 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/06/2011 |
Last Update Date | 25/03/2021 |