Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 4964 | KY |
Y | 213EG0000X | General Practice | 4964 | KY |
NPI | 1538276779 |
---|---|
Provider Name | Owen Wayne Mortenson |
First Address | Middletown, KY 40243-1426 |
Second Address | Middletown, KY 40243-1426 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/08/2006 |
Last Update Date | 08/07/2007 |