Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 28129 | KY |
Y | 207QS0010X | Family Doctor - Sports Medicine | 28129 | KY |
NPI | 1063478675 |
---|---|
Provider Name | William S Black |
First Address | Owensboro, KY 42304-3229 |
Second Address | Owensboro, KY 42301-4677 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/04/2006 |
Last Update Date | 25/08/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
64281298 | (05) | KY |
F27732 | (02) |