Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | 06424 | MS |
NPI | 1114087483 |
---|---|
Provider Name | David Butler Johnson |
First Address | Yazoo City, MS 39194-2511 |
Second Address | Yazoo City, MS 39194-2511 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/12/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0123708 | (05) | MS |
D85910 | (02) | MS |