Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207RC0200X | Critical Care Medicine | 07368R | LA |
Y | 207RP1001X | Pulmonary Disease | 07368R | LA |
NPI | 1053305482 |
---|---|
Provider Name | Mr. Walter Dwayne Brown |
First Address | Lafayette, LA 70503-2852 |
Second Address | Lafayette, LA 70503-2852 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2005 |
Last Update Date | 06/12/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1929255 | (05) | LA |
D79341 | (02) |