Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | 6990A | WY |
NPI | 1003922360 |
---|---|
Provider Name | Dr. William R Smith |
First Address | Jackson, WY 83001-0428 |
Second Address | Jackson, WY 83001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/08/2006 |
Last Update Date | 18/02/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
120132800 | (05) | WY |
I11617 | (02) |