Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2086S0102X | Surgical Critical Care | 2013039276 | MO |
NPI | 1104053032 |
---|---|
Provider Name | Dr. Justin Gawron Knittel |
First Address | Saint Louis, MO 63110-1010 |
Second Address | Saint Louis, MO 63110-1003 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/06/2009 |
Last Update Date | 15/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200015703 | (05) | MO |