Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224P00000X | Prosthetist | CP003902 |
NPI | 1427317429 |
---|---|
Provider Name | Seth O'brien |
First Address | Mesa, AZ 85202-6456 |
Second Address | Mesa, AZ 85202 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/05/2012 |
Last Update Date | 06/06/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
CP003902 | ABC CERTIFICATION (01) |