Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RI0200X | Infectious Disease | 04-30882 | KS |
NPI | 1043313968 |
---|---|
Provider Name | Stephen C Waller |
First Address | Kansas City, KS 66160 |
Second Address | Kansas City, KS 66160 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/09/2006 |
Last Update Date | 08/05/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200263690A | (05) | KS |
205362312 | (05) | MO |
34056011 | BCBS KC (01) | MO |
580860 | FIRSTGUARD (01) | KS |
H41503 | (02) |