Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0122X | Plastic and Reconstructive Surgery | 0419242 | KS |
NPI | 1316030638 |
---|---|
Provider Name | Dr. Stacy L Peterson |
First Address | Wichita, KS 67214-3729 |
Second Address | Wichita, KS 67214-3729 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
B69280 | (02) |