Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | LAT-2586 | NC |
NPI | 1407407612 |
---|---|
Provider Name | Russell Sineni |
First Address | Raleigh, NC 27616-5704 |
Second Address | Raleigh, NC 27616-5704 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/09/2019 |
Last Update Date | 28/09/2019 |