Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207L00000X | Anesthesiologist | 10069 | ND |
Y | 207L00000X | Anesthesiologist | MED-PHYS-LIC-52109 | MT |
NPI | 1013028091 |
---|---|
Provider Name | Kenyon W Kruse |
First Address | Kalispell, MT 59904-1210 |
Second Address | Kalispell, MT 59901-3129 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2006 |
Last Update Date | 07/11/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
13544 | (05) | ND |
H71196 | (02) | ND |