Basic Information
| Provider Information | |||||||||
| NPI: | 1750941456 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUSSELIER | ||||||||
| FirstName: | JACOB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 GILLHAM RD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641084619 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 2401 GILLHAM RD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641084619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162343000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2019 | ||||||||
| LastUpdateDate: | 06/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 2019020369 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
No ID Information.