Provider Demographics
NPI:1366457038
Name:RIEMER, GUSTAV THOMAS (PA)
Entity Type:Individual
Prefix:
First Name:GUSTAV
Middle Name:THOMAS
Last Name:RIEMER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9119 W. 74TH STREET, SUITE 354
Mailing Address - Street 2:SHAWNEE MISSION MEDICAL BUILDING
Mailing Address - City:MERRIAM
Mailing Address - State:KS
Mailing Address - Zip Code:66204
Mailing Address - Country:US
Mailing Address - Phone:913-894-2121
Mailing Address - Fax:913-894-9592
Practice Address - Street 1:9119 W. 74TH STREET, SUITE 354
Practice Address - Street 2:SHAWNEE MISSION MEDICAL BUILDING
Practice Address - City:MERRIAM
Practice Address - State:KS
Practice Address - Zip Code:66204
Practice Address - Country:US
Practice Address - Phone:913-894-2121
Practice Address - Fax:913-894-9592
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00862363AS0400X
MO2008018557363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427061Medicare UPIN
KSW550000Medicare PIN
KSW55D443Medicare PIN
KS427061Medicare PIN