Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | 26811 | TN |
NPI | 1689644320 |
---|---|
Provider Name | Laurent Legault |
First Address | Kingsport, TN 37660-5839 |
Second Address | Kingsport, TN 37660-5839 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/01/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G32844 | (02) | TN |