Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | 903674 | MS |
NPI | 1174163620 |
---|---|
Provider Name | Ms. Samantha Smith |
First Address | Madison, MS 39110-6544 |
Second Address | Canton, MS 39046-4502 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/01/2020 |
Last Update Date | 13/01/2020 |