Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213E00000X | Podiatrist | POD001150 | GA |
N | 222Z00000X | Podiatrist | POD001150 | GA |
Y | 213ES0103X | Foot & Ankle Surgery | POD001150 | GA |
NPI | 1083916720 |
---|---|
Provider Name | Dr. Ebony Lashay Love |
First Address | Philadelphia, PA 19107-2418 |
Second Address | Philadelphia, PA 19107-2418 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/12/2010 |
Last Update Date | 03/04/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
003118774A | (05) | GA |
202I481075 | INDIVIDUAL MEDICARE PTAN (01) | GA |
511G700902 | GROUP MEDICARE PTAN (01) | GA |