Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213E00000X | Podiatrist | 000066 | GA |
N | 222Z00000X | Podiatrist | 000066 | GA |
Y | 213E00000X | Podiatrist | ORT44 | FL |
Y | 222Z00000X | Podiatrist | ORT44 | FL |
NPI | 1053314682 |
---|---|
Provider Name | Kenneth A Wells |
First Address | Tallahassee, FL 32308-8405 |
Second Address | Tallahassee, FL 32308-4470 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/05/2005 |
Last Update Date | 22/06/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
409058070A | (05) | GA |