Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | DOS-376 | HI |
N | 207PE0004X | Emergency Medical Services | 2066 | AZ |
NPI | 1033177605 |
---|---|
Provider Name | Dr. Darrel Wayn Killebrew |
First Address | Phoenix, AZ 85022-3739 |
Second Address | Pahala, HI 96777 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2006 |
Last Update Date | 16/08/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
263681 | HMSA (01) | HI |
58799101 | (05) | HI |
E97844 | (02) | AZ |