Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080A0000X | Adolescent Medicine | A124606 | CA |
NPI | 1104116680 |
---|---|
Provider Name | Paul Michael Imus |
First Address | La Mesa, CA 91942-3135 |
Second Address | La Mesa, CA 91942-3135 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/04/2011 |
Last Update Date | 18/04/2016 |