Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 24389 | WV |
Y | 2080P0202X | Pediatric Cardiologist | 24389 | WV |
NPI | 1023222197 |
---|---|
Provider Name | Jackie R Stines JR. |
First Address | Huntington, WV 25701 |
Second Address | Huntington, WV 25701 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/05/2007 |
Last Update Date | 09/12/2021 |