Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 256321 | NY |
NPI | 1124129119 |
---|---|
Provider Name | Tally Edward Lassiter JR. |
First Address | Cooperstown, NY 13326-0725 |
Second Address | Oneonta, NY 13820-2266 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/09/2006 |
Last Update Date | 12/06/2012 |