Provider Demographics
NPI:1124390620
Name:NURRENBERN, GREGORY (NP)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:NURRENBERN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64124-2323
Mailing Address - Country:US
Mailing Address - Phone:816-889-4730
Mailing Address - Fax:816-889-1847
Practice Address - Street 1:825 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64124-2323
Practice Address - Country:US
Practice Address - Phone:816-889-4730
Practice Address - Fax:816-889-1847
Is Sole Proprietor?:No
Enumeration Date:2012-01-31
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012003063363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1124390620Medicaid
MO2012003063OtherLICENSE