Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | 2081S0010X | CA |
Y | 213ES0000X | Sports Medicine | 2081S0010X | CA |
NPI | 1326532417 |
---|---|
Provider Name | Nicolas Simo |
First Address | Walnut, CA 91789-4185 |
Second Address | Walnut, CA 91789-4185 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2018 |
Last Update Date | 21/06/2018 |