Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213EP1101X | Primary Podiatric Medicine | E3455 | CA |
NPI | 1467437624 |
---|---|
Provider Name | Kenneth Wells |
First Address | San Diego, CA 92114-3610 |
Second Address | San Diego, CA 92114-3610 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/12/2005 |
Last Update Date | 23/11/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000E34550 | (05) | CA |
T19336 | (02) | CA |