Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | 14413 | MS |
NPI | 1023046711 |
---|---|
Provider Name | John C Brooks |
First Address | Jackson, MS 39236-6076 |
Second Address | Jackson, MS 39202-2064 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/06/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00117257 | (05) | MS |
G20416 | (02) | MS |