Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VX0201X | Gynecologic Oncologist | 18985 | MS |
NPI | 1134111867 |
---|---|
Provider Name | Mildred Ridgway |
First Address | Jackson, MS 39216-4643 |
Second Address | Jackson, MS 39216-4643 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/08/2005 |
Last Update Date | 23/07/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2195115 | (05) | LA |
H61238 | (02) |