Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225000000X | Orthotic Fitter |
NPI | 1669592804 |
---|---|
Provider Name | Gene Shirley |
First Address | Fayetteville, NC 28304-3455 |
Second Address | Fayetteville, NC 28304-3455 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/03/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
7795271 | (05) | NC |