Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | R9N60 | MO |
N | 207ND0101X | MOHS-Micrographic Surgeon | R9N30 | MO |
N | 207NP0225X | Pediatric Dermatologist | R9N30 | MO |
N | 207NS0135X | Procedural Dermatology | R9N30 | MO |
NPI | 1477554657 |
---|---|
Provider Name | Gary W Mcewen |
First Address | Lee's Summit, MO 64086-5696 |
Second Address | Lee's Summit, MO 64086-5696 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/08/2005 |
Last Update Date | 22/08/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G68624 | (02) | MO |
P00412861 | RAILROAD PTAN (01) | MO |