Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RX0202X | Medical Oncology | 2013011512 | MO |
NPI | 1174787162 |
---|---|
Provider Name | Dr. Jesse Wade Keller |
First Address | Saint Louis, MO 63110-1010 |
Second Address | Saint Louis, MO 63141-6287 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/07/2008 |
Last Update Date | 15/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200032614 | (05) | MO |