Provider Demographics
NPI:1346471745
Name:PRUDHOMME, GOLNAR (DPM)
Entity Type:Individual
Prefix:DR
First Name:GOLNAR
Middle Name:
Last Name:PRUDHOMME
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 1ST TER
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:KS
Mailing Address - Zip Code:66043-1703
Mailing Address - Country:US
Mailing Address - Phone:440-785-8604
Mailing Address - Fax:
Practice Address - Street 1:4101 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-5014
Practice Address - Country:US
Practice Address - Phone:913-682-2000
Practice Address - Fax:913-758-4177
Is Sole Proprietor?:No
Enumeration Date:2009-08-03
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSPP-26213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist