Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | 125052276 | IL |
Y | 207ND0101X | MOHS-Micrographic Surgeon | A118004 | CA |
NPI | 1255523569 |
---|---|
Provider Name | Susan L Boone |
First Address | Elk Grove, CA 95758-1240 |
Second Address | Sacramento, CA 95864 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/08/2007 |
Last Update Date | 11/02/2022 |