Individual
EDISON DERR II
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
2214 MAPLE ST, SAINT JOSEPH, MO 64507-1413
(419) 651-2323
Mailing address
2214 MAPLE ST, SAINT JOSEPH, MO 64507-1413
(419) 651-2323
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
2013032471
MO
Other
Enumeration date
06/15/2015
Last updated
06/15/2015
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