Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | 40256 | WI |
N | 207Q00000X | Family Doctor | 40256 | WI |
NPI | 1003936857 |
---|---|
Provider Name | Kelly Ann Carothers |
First Address | La Crosse, WI 54601-5429 |
Second Address | La Crosse, WI 54601-5429 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/03/2007 |
Last Update Date | 27/05/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
32474400 | (05) | WI |
G75117 | (02) | WI |