Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 23919 | WV |
Y | 208D00000X | General Practice Physician | 23919 | WV |
NPI | 1043486145 |
---|---|
Provider Name | Dr. James Namsupak |
First Address | Fairmont, WV 26554-4029 |
Second Address | Fairmont, WV 26554-4029 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/05/2008 |
Last Update Date | 16/09/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3810016983 | (05) | WV |