Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207VX0201X | Gynecologic Oncologist | 01058411A | IN |
Y | 207VX0201X | Gynecologic Oncologist | 72318 | GA |
NPI | 1538156187 |
---|---|
Provider Name | Kelly J. Manahan |
First Address | Fort Wayne, IN 46804-7934 |
Second Address | Columbus, GA 31904-8915 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/09/2005 |
Last Update Date | 31/08/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200135230A | (05) | IN |
G78599 | (02) | IN |