Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111NR0400X | Rehabilitation Chiropractor | KS-01-05421 | KS |
Y | 111NS0005X | Chiropractic Sports Physician | KS-01-05421 | KS |
NPI | 1023421179 |
---|---|
Provider Name | Bradley William Carolan |
First Address | Overland Park, KS 66210-1401 |
Second Address | Overland Park, KS 66210-1401 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/06/2014 |
Last Update Date | 10/06/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
12285054 | CAQH (01) |