Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VG0400X | Gynecologist | 18542 | KY |
N | 207VX0000X | Obstetrician | 18542 | KY |
NPI | 1407872559 |
---|---|
Provider Name | Waller Lisle Dalton |
First Address | Lexington, KY 40508-3215 |
Second Address | Lexington, KY 40536-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/07/2006 |
Last Update Date | 19/03/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
64185424 | (05) | KY |
C78378 | (02) |