Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VG0400X | Gynecologist | 5592A | WY |
NPI | 1104822972 |
---|---|
Provider Name | Dr. Henry Thomas Smith |
First Address | Jackson, WY 83002-8760 |
Second Address | Jackson, WY 83001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/06/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
303832 | BLUE CROSS BLUE SHIELD (01) | WY |
E28199 | (02) | WY |