Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | 0414492 | KS |
N | 207ND0101X | MOHS-Micrographic Surgeon | 0414492 | KS |
N | 207ND0900X | Dermatopathologist | 0414492 | KS |
NPI | 1104929553 |
---|---|
Provider Name | Wallace Nicholas Weber |
First Address | Dorrance, KS 67634 |
Second Address | Dorrance, KS 67634 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/09/2006 |
Last Update Date | 19/11/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
B68642 | (02) |