| NPI | 1235643891 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JENNIFER ROBIN BONNEY Manager/ Billing 228-254-0495 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: LA MD.206408) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: LA MD016771) |
| 207ND0900X Dermatology, Dermatopathology (Licence: LA 16771) | |
| Enumeration Date | 2017-11-18 |
| Last Update Date | 2017-11-18 |