Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 2020019358 | MO |
NPI | 1003445990 |
---|---|
Provider Name | Matthew Timothy Myrick |
First Address | Kansas City, MO 64139-1246 |
Second Address | Kansas City, MO 64139-1246 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/04/2020 |
Last Update Date | 25/08/2020 |