Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | X010482-1 | NY |
NPI | 1073606877 |
---|---|
Provider Name | Randal Robert Boivin |
First Address | Baldwinsville, NY 13027-2425 |
Second Address | Baldwinsville, NY 13027-2425 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/10/2006 |
Last Update Date | 20/09/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U92425 | (02) | NY |