Healthcare Provider Details

I. General information

NPI: 1104319748
Provider Name (Legal Business Name): ETHAN STEED JAEGER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2018
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10730 NALL AVE STE 200
OVERLAND PARK KS
66211-1285
US

IV. Provider business mailing address

10730 NALL AVE STE 20010730
OVERLAND PARK KS
66211-1366
US

V. Phone/Fax

Practice location:
  • Phone: 913-588-1227
  • Fax:
Mailing address:
  • Phone: 913-588-1227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number05-46502
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: