Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 04-21889 | KS |
NPI | 1003825720 |
---|---|
Provider Name | Antonio Lazaro Carro |
First Address | Mulvane, KS 67110-1109 |
Second Address | Mulvane, KS 67110-1109 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/08/2006 |
Last Update Date | 25/10/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
057433 | BC/BS (01) | KS |
E84244 | (02) | KS |