Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | 2009005829 | MO |
Y | 213ES0000X | Sports Medicine | 2009005829 | MO |
NPI | 1073166864 |
---|---|
Provider Name | Bryan Bengston |
First Address | Saint Louis, MO 63126-1030 |
Second Address | Saint Louis, MO 63126-1030 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/07/2019 |
Last Update Date | 20/07/2019 |