Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | 0416062 | KS |
NPI | 1023042926 |
---|---|
Provider Name | Wineetha Fernando |
First Address | Larned, KS 67550-5353 |
Second Address | Larned, KS 67550-5353 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/07/2006 |
Last Update Date | 24/07/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E36729 | (02) |