Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 01-05967 | KS |
NPI | 1104384981 |
---|---|
Provider Name | Samuel Somerhalder JR. |
First Address | Overland Park, KS 66213-1116 |
Second Address | Overland Park, KS 66213-1116 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/03/2019 |
Last Update Date | 11/03/2019 |