Individual
JASPER FULLARD
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
5746 N BROADWAY ST, KANSAS CITY, MO 64118-3998
(816) 912-4539
(855) 813-6642
Mailing address
PO BOX 1239, TROY, MI 48099-1239
(248) 824-6600
(855) 618-6655
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
04-16758
KS
207R00000X
Internal Medicine Physician
Primary
R7174
MO
207RG0300X
Geriatric Medicine (Internal Medicine) Physician
04-16758
KS
207RG0300X
Geriatric Medicine (Internal Medicine) Physician
R7174
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100093400F
—
KS
Enumeration date
06/08/2006
Last updated
07/10/2014
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