Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207X00000X | Orthopaedic Surgeon | 04-41486 | KS |
N | 207X00000X | Orthopaedic Surgeon | 2016016714 | MO |
N | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 04-41486 | KS |
N | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 2016016714 | MO |
NPI | 1215258736 |
---|---|
Provider Name | Dr. Michael Gabriel Azzam |
First Address | Prairie Village, KS 66207-2522 |
Second Address | Prairie Village, KS 66207-2522 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/06/2010 |
Last Update Date | 18/06/2021 |