Healthcare Provider Details

I. General information

NPI: 1003003310
Provider Name (Legal Business Name): WEST COLLEGE DERMATOLOGY & AESTHETICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11041 HAUSER ST
LENEXA KS
66210-3708
US

IV. Provider business mailing address

11041 HAUSER ST
LENEXA KS
66210-3708
US

V. Phone/Fax

Practice location:
  • Phone: 913-888-3376
  • Fax: 913-888-3386
Mailing address:
  • Phone: 913-888-3376
  • Fax: 913-888-3386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number04-25210
License Number StateKS

VIII. Authorized Official

Name: MICHAEL LEE HAAG
Title or Position: OWNER
Credential: MD
Phone: 913-888-3376