Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NR0200X | Radiology | 004447 | MO |
Y | 213ER0200X | Radiology | 004447 | MO |
NPI | 1962447649 |
---|---|
Provider Name | Norman Kettner |
First Address | Chesterfield, MO 63017-5529 |
Second Address | Chesterfield, MO 63017-5529 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/06/2006 |
Last Update Date | 18/07/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T43362 | (02) | MO |