Basic Information
| Provider Information | |||||||||
| NPI: | 1780785949 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | JEFFRY | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT CH 14389 | ||||||||
| Address2: | |||||||||
| City: | PALATINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600554389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852958108 | ||||||||
| FaxNumber: | 7852315991 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 SW 7TH ST | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666061674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852958359 | ||||||||
| FaxNumber: | 7852315988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 07/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 45550 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | H163151 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 200332830A | 05 | KS | MEDICAID |