Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207ND0900X | Dermatopathologist | 061214 | GA |
N | 207NS0135X | Procedural Dermatology | 61214 | GA |
NPI | 1780803098 |
---|---|
Provider Name | Dr. Jill Buckthal-Mccuin |
First Address | Newnan, GA 30263-2384 |
Second Address | Greensboro, GA 30642-5285 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/04/2007 |
Last Update Date | 09/06/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
874913241A | (05) | GA |
P00693238 | RAILROAD MEDICARE (01) | GA |