Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207T00000X | Neurosurgeon | 22126 | SC |
NPI | 1073095683 |
---|---|
Provider Name | Kimberly Sue Bregenzer |
First Address | Atlanta, GA 30374-3904 |
Second Address | Columbia, SC 29203-6862 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2018 |
Last Update Date | 27/12/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
NP5438 | (05) | SC |