Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | SC002230L | PA |
Y | 222Z00000X | Podiatrist | SC002230L | PA |
NPI | 1063426500 |
---|---|
Provider Name | Carol Ann Kunkle |
First Address | Latrobe, PA 15650-1502 |
Second Address | Latrobe, PA 15650-1502 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/07/2006 |
Last Update Date | 11/09/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0007691290001 | (05) | PA |
1457675 | BLUE SHIELD (01) | PA |
T29848 | (02) | PA |
T29848 | DEA (01) | PA |