Individual
KENNETH BRYAN GAUTIER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
103 HALLS CV, SENATOBIA, MS 38668-6620
(662) 562-9003
Mailing address
103 HALLS CV, SENATOBIA, MS 38668-6620
(662) 562-9003
Taxonomy
Speciality
Code
Description
License number
State
2080S0010X
Pediatric Sports Medicine Physician
Primary
18615
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
06727534
—
MS
Enumeration date
09/22/2006
Last updated
02/29/2012
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