Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | KS |
NPI | 1083884647 |
---|---|
Provider Name | Mr. Ryan Jay Storey |
First Address | Wichita, KS 67217-3209 |
Second Address | Wichita, KS 67217-3209 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/03/2008 |
Last Update Date | 10/03/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5002710001 | (02) | KS |