Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | 101805 | MO |
NPI | 1134291107 |
---|---|
Provider Name | James D Bullard |
First Address | Lees Summit, MO 64063-5127 |
Second Address | Blue Springs, MO 64014-0900 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/11/2006 |
Last Update Date | 05/09/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
22381016 | BLUE CROSS BLUE SHIELD IN (01) | MO |
486710726 | (05) | MO |