Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | L7669 | TX |
Y | 2086S0120X | Pediatric Surgery | 19633 | MS |
NPI | 1477524502 |
---|---|
Provider Name | Dr. Christopher Blewett |
First Address | Jackson, MS 39216-4500 |
Second Address | Jackson, MS 39216-4500 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/01/2006 |
Last Update Date | 14/06/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
06002844 | (05) | MS |
150671901 | (05) | TX |
F78273 | (02) | TX |