Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204C00000X | Sports Medicine Doctor | 0101052700 | VA |
N | 208100000X | Physical Medicine & Rehabilitation Doctor | 0101052700 | VA |
Y | 2081P2900X | Pain Medicine | 0101052700 | VA |
NPI | 1679543078 |
---|---|
Provider Name | Ms. Winifred Diane Bragg |
First Address | Norfolk, VA 23502-3933 |
Second Address | Norfolk, VA 23502-3933 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/01/2006 |
Last Update Date | 01/06/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G17089 | (02) | VA |