Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2080P0207X | Pediatric Hematology-Oncologist | 04-23044 | KS |
Y | 2080P0207X | Pediatric Hematology-Oncologist | R8H41 | MO |
NPI | 1275599417 |
---|---|
Provider Name | Dr. Brian Montgomery Wicklund |
First Address | Kansas City, MO 64108-4619 |
Second Address | Kansas City, MO 64108-4619 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/04/2006 |
Last Update Date | 17/06/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100117230A | (05) | KS |
202615506 | (05) | MO |
E65109 | (02) |