Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | 21284 | NV |
N | 208000000X | Pediatrician | A152715 | CA |
NPI | 1003278425 |
---|---|
Provider Name | Sora Song |
First Address | Long Beach, CA 90806-1701 |
Second Address | Las Vegas, NV 89109-2428 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/03/2016 |
Last Update Date | 30/11/2021 |