Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207X00000X | Orthopaedic Surgeon | 0101036314 | VA |
NPI | 1033147376 |
---|---|
Provider Name | Kenneth Gray |
First Address | Radford, VA 24141-2339 |
Second Address | Radford, VA 24141-2339 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
B05298 | (02) |