Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213EP1101X | Primary Podiatric Medicine | 000750 | MO |
N | 213EP1101X | Primary Podiatric Medicine | 1200289 | KS |
NPI | 1336245125 |
---|---|
Provider Name | Dr. Boremy Ly |
First Address | Kansas City, MO 64151-1532 |
Second Address | Kansas City, MO 64151-1532 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/09/2006 |
Last Update Date | 28/02/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
308630318 | (05) | MO |
U63260 | (02) |