Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | 3010988 | KY |
NPI | 1023521317 |
---|---|
Provider Name | Mary Ann Smith |
First Address | Cold Spring, KY 41076-3522 |
Second Address | Southgate, KY 41071-3234 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/11/2017 |
Last Update Date | 09/11/2017 |