NPI | 1326576026 |
---|---|
Former Name | KELLY SOUDER |
Entity Type | Individual |
Gender | Female |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 7082) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA 6095) |
Enumeration Date | 2017-05-25 |
Last Update Date | 2025-07-22 |