Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | 20211016497 | MO |
N | 363LP2300X | Nurse Practitioner - Primary Care | 20211016497 | MO |
NPI | 1033780739 |
---|---|
Provider Name | Christopher Joe La Rose |
First Address | Gordon, NE 69343-0481 |
Second Address | Gordon, NE 69343-1199 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/07/2021 |
Last Update Date | 08/07/2021 |