Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207PE0004X | Emergency Medical Services | A89644 | CA |
N | 207Q00000X | Family Doctor | A89644 | CA |
NPI | 1174574404 |
---|---|
Provider Name | Peter Lue |
First Address | Victorville, CA 92395-5794 |
Second Address | Victorville, CA 92395-5794 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/05/2006 |
Last Update Date | 13/04/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00A896440 | (05) | CA |
I50405 | (02) |