Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0004X | Dentist Anesthesiologist | D10072 | AZ |
NPI | 1841604659 |
---|---|
Provider Name | Tyler Tomkinson |
First Address | Casa Grande, AZ 85122-6381 |
Second Address | Phoenix, AZ 85023 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/06/2014 |
Last Update Date | 31/08/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
404557 | (05) | AZ |