Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 44097 | KS |
NPI | 1003811399 |
---|---|
Provider Name | Mr. Norman Keith Trevolt |
First Address | Wichita, KS 67214-3858 |
Second Address | Wichita, KS 67214-3858 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2005 |
Last Update Date | 07/02/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100415820A | (05) | KS |
100415820E | (05) | KS |
P51841 | (02) | KS |