Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 04-20172 | KS |
N | 207QS0010X | Family Doctor - Sports Medicine | 04-20172 | KS |
NPI | 1306855069 |
---|---|
Provider Name | David Wayne Niederee |
First Address | Derby, KS 67037-3735 |
Second Address | Derby, KS 67037-3735 |
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 |
---|---|---|
057436 | BC/BS (01) | KS |
B69231 | (02) | KS |