Provider Demographics
NPI:1568712842
Name:SALLS, WILLIAM JAY (CNP)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JAY
Last Name:SALLS
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:
Other - Last Name:SALLS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSN/FNP-BC
Mailing Address - Street 1:PO BOX 800022
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-0022
Mailing Address - Country:US
Mailing Address - Phone:800-953-0104
Mailing Address - Fax:303-765-6640
Practice Address - Street 1:2573 STATE HIGHWAY 522
Practice Address - Street 2:
Practice Address - City:QUESTA
Practice Address - State:NM
Practice Address - Zip Code:87556
Practice Address - Country:US
Practice Address - Phone:575-586-0315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COC-APN.0000331-C-NP363LF0000X
NMCNP-02608363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000179996Medicaid