Individual
BUNRY PIN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
911 SUNSET DR, HOLLISTER, CA 95023-5606
(831) 637-5711
Mailing address
2150 SPINEL CT, HOLLISTER, CA 95023-6661
(831) 801-1946
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
19951
CA
208600000X
Surgery Physician
PG182724
OR
Other
Enumeration date
05/01/2017
Last updated
12/29/2022
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