Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207RA0401X | Internist - Addiction Medicine | 048166 | CT |
NPI | 1659340651 |
---|---|
Provider Name | Nermina Bukalo |
First Address | Manchester, CT 06040-4131 |
Second Address | Manchester, CT 06040-4131 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/03/2006 |
Last Update Date | 24/08/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2143143 | (05) | MA |
I41347 | (02) |