Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 35.139496 | OH |
Y | 2080P0204X | Pediatric Emergency Doctor | 35.139496 | OH |
NPI | 1023549409 |
---|---|
Provider Name | Kali Broussard |
First Address | Columbus, OH 43205-2664 |
Second Address | Columbus, OH 43205-2664 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/03/2017 |
Last Update Date | 02/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0468063 | (05) | OH |