Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 107790 | MO |
Y | 111NI0900X | Internist | 107790 | MO |
N | 207RG0300X | Geriatric Medicine | 107790 | MO |
NPI | 1083609077 |
---|---|
Provider Name | Pamela Maben |
First Address | Independence, MO 64055-7005 |
Second Address | Independence, MO 64055-7005 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/09/2005 |
Last Update Date | 20/09/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100151230 C | (05) | KS |
100151230B | (05) | KS |
208995803 | (05) | MO |
B68814 | (02) | MO |