Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | 5912 | AL |
NPI | 1700142015 |
---|---|
Provider Name | Ashley Kyle Wasserman |
First Address | Mobile, AL 36652-2867 |
Second Address | Eight Mile, AL 36613-3563 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/04/2012 |
Last Update Date | 09/07/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
011846 | MAIN GROUP MEDICARE PAYEE NUMBER (01) | AL |
1063439065 | NPI MAIN GROUP PAYEE NUMBER (01) | AL |
630000013 | (05) | AL |