Provider Demographics
NPI:1396739843
Name:BECKER, NANCY JO (MD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:JO
Last Name:BECKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13104 S HOMESTEAD LN
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061
Mailing Address - Country:US
Mailing Address - Phone:913-706-0794
Mailing Address - Fax:913-661-9173
Practice Address - Street 1:13104 S HOMESTEAD LN
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-9686
Practice Address - Country:US
Practice Address - Phone:913-706-0794
Practice Address - Fax:913-661-9173
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2016-02-03
Deactivation Date:2011-03-09
Deactivation Code:
Reactivation Date:2016-01-26
Provider Licenses
StateLicense IDTaxonomies
KSAB2368555174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
C50616Medicare UPIN
KS6386914Medicare PIN