Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | POD001378 | GA |
Y | 222Z00000X | Podiatrist | POD001378 | GA |
N | 213ES0103X | Foot & Ankle Surgery | POD001378 | GA |
NPI | 1043689623 |
---|---|
Provider Name | Kibibi Wanzu |
First Address | Hampton, GA 30228-1864 |
Second Address | Hampton, GA 30228-1864 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/09/2015 |
Last Update Date | 02/07/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
003207314 | (05) | GA |
003207314G | (05) | GA |
14312441 | CAQH (01) | GA |