Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | J0551 | TX |
NPI | 1134158611 |
---|---|
Provider Name | Scott Kimball |
First Address | Norman, OK 73070-5270 |
Second Address | College Station, TX 77845-8345 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
F21156 | (02) |