Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0120X | Pediatric Surgery | MD40166 | TN |
NPI | 1508854324 |
---|---|
Provider Name | Lesli A Taylor |
First Address | Mountain Home, TN 37684-0699 |
Second Address | Johnson City, TN 37604-6056 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/10/2005 |
Last Update Date | 16/06/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
B95341 | (02) |