Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | 1234 | KS |
N | 103T00000X | Psychologist | 1234 | KS |
Y | 103G00000X | Clinical Psychologist | PSY-202376 | ID |
Y | 103TC0700X | Clinical Psychologist | PSY-202376 | ID |
NPI | 1013952134 |
---|---|
Provider Name | Trever L Patton |
First Address | Wichita, KS 67207-3123 |
Second Address | Wichita, KS 67207-3123 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/06/2006 |
Last Update Date | 12/02/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
16849372 | MEDICARE GROUP PIN (01) | ID |
N6300 | BLUE CROSS (01) | ID |
P99762 | (02) | KS |