Individual
Inactive
Sole proprietor
Provider details
NPI number
Contact information
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
11217
NE
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
47057331013
—
NE
Enumeration date
—
Last updated
—
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