Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | A84458 | CA |
Y | 2080N0001X | Neonatal-Perinatal Doctor | A84458 | CA |
NPI | 1114031762 |
---|---|
Provider Name | Shelley Bose |
First Address | Los Angeles, CA 90054-0559 |
Second Address | Orange, CA 92868-3201 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/08/2006 |
Last Update Date | 08/12/2021 |