Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | R872675 | MS |
NPI | 1003111543 |
---|---|
Provider Name | Mrs. Leslie Estes Shavers |
First Address | Gulfport, MS 39503-7621 |
Second Address | Pascagoula, MS 39567-3416 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/01/2011 |
Last Update Date | 27/06/2011 |