Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2086S0120X | Pediatric Surgery | 40928 | MN |
Y | 2086S0120X | Pediatric Surgery | MD60987 | TN |
NPI | 1437110004 |
---|---|
Provider Name | Brad A Feltis |
First Address | Mountain Home, TN 37684-0699 |
Second Address | Johnson City, TN 37604-6171 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/03/2006 |
Last Update Date | 31/07/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
108781900 | (05) | MN |
G89760 | (02) | MN |