Basic Information
| Provider Information | |||||||||
| NPI: | 1861081804 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEAN | ||||||||
| FirstName: | BOB | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 224 N TAYLOR AVE | ||||||||
| Address2: | |||||||||
| City: | GARDEN CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 678465130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6206404645 | ||||||||
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| Practice Location | |||||||||
| Address1: | 712A SAINT JOHN ST | ||||||||
| Address2: | |||||||||
| City: | GARDEN CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 678465128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202751766 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2021 | ||||||||
| LastUpdateDate: | 02/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 79117 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.