Facts
- Status
- A
- Credential
- DC
- Type
- Individual
- Enumeration date
- 2006-02-23
- Last updated
- 2026-07-13
Specialties
Licenses
- License KS
- 01-04870
Location
- Practice location
- 1701 E MADISON AVE, STE A
- City
- DERBY KS
- Postal code
- 670372079
- Phone
- 316-788-3713
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
The OIG NPI list is not in this build yet. Confirm on OIG's search.
Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.