Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LC0200X | Nurse Practitioner - Critical Care Medicine | 2016005298 | MO |
NPI | 1306206677 |
---|---|
Provider Name | Mara Wear |
First Address | St. Louis, MO 63150 |
Second Address | Kansas City, MO 64111 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/03/2016 |
Last Update Date | 01/03/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2016005298 | NP LICENSE (01) | MO |