MEDICARE: GERARD PRIGGEL DIETRICH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1114690211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GERARD PRIGGEL DIETRICH

Provider Business Mailing Address
First Line	:	4414 PENNSYLVANIA AVE APT 6
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64111-3326
Country	:	US
Telephone Number	:	417-293-9682
Fax Number	:

Provider Business Practice Location Address
First Line	:	4320 WORNALL RD STE 65
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64111-5945
Country	:	US
Telephone Number	:	816-932-6100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2021
Last Update Date	:	07/26/2021

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