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General NPI Number Information
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NPI Number | 1447191259
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Entity Type | Individual
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Provider Name | JEREMY SUDOL APRN
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Gender | Male
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Dates
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Enumeration Date | 04/03/2026
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Last Update Date | 04/03/2026
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Provider Practice Location Address
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Address Line | 412 LONG PATH CT
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City | GODDARD
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State | KS
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Zip | 67052-4302
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Country | US
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Telephone | 201-314-3570
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Fax |
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Provider Business Mailing Address
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Address Line | 412 LONG PATH CT
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City | GODDARD
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State | KS
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Zip | 67052-4302
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Country | US
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Telephone | 201-314-3570
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number | 53-85462-012
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License Number State | KS
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