Basic Information
| Provider Information | |||||||||
| NPI: | 1134654551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKELLAR | ||||||||
| FirstName: | MIRANDA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | MIRANDA | ||||||||
| OtherMiddleName: | S | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 807 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | NORTON | ||||||||
| State: | KS | ||||||||
| PostalCode: | 676541403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858773305 | ||||||||
| FaxNumber: | 7858773076 | ||||||||
| Practice Location | |||||||||
| Address1: | 807 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | NORTON | ||||||||
| State: | KS | ||||||||
| PostalCode: | 676541403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858773305 | ||||||||
| FaxNumber: | 7858773076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2017 | ||||||||
| LastUpdateDate: | 07/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 04-41203 | KS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.