Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | LL52743 | SC |
Y | 208600000X | Surgeon | LL52743 | SC |
NPI | 1013401843 |
---|---|
Provider Name | Michael David Tichenor |
First Address | Columbia, SC 29203 |
Second Address | Columbia, SC 29203 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2018 |
Last Update Date | 15/06/2018 |