1235171661 NPI number — AMANDA HUMISTON MD

Table of content: AMANDA HUMISTON MD (NPI 1235171661)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235171661 NPI number — AMANDA HUMISTON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUMISTON
Provider First Name:
AMANDA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235171661
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2790 CLAY EDWARDS DR
Provider Second Line Business Mailing Address:
SUITE 1200
Provider Business Mailing Address City Name:
NORTH KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64116-3276
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-468-7800
Provider Business Mailing Address Fax Number:
816-468-8531

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2790 CLAY EDWARDS DR
Provider Second Line Business Practice Location Address:
SUITE 1200
Provider Business Practice Location Address City Name:
NORTH KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64116-3276
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-468-7800
Provider Business Practice Location Address Fax Number:
816-468-8531
Provider Enumeration Date:
06/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  2006013773 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2006013773 . This is a "STATE LICENSE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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