Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 35.142248 | OH |
NPI | 1003312760 |
---|---|
Provider Name | Sara Jane Brown |
First Address | Willowick, OH 44095-3748 |
Second Address | Mentor, OH 44060-8702 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/04/2018 |
Last Update Date | 29/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0293379 | (05) | OH |