Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0129X | Vascular Surgeon | 82162 | SC |
NPI | 1104237338 |
---|---|
Provider Name | William Jackson |
First Address | Florence, SC 29506-2624 |
Second Address | Florence, SC 29506-2624 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/05/2014 |
Last Update Date | 03/02/2021 |