Healthcare Provider Details

I. General information

NPI: 1093828097
Provider Name (Legal Business Name): STONECREEK FAMILY PHYSICIANS, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 ANDERSON AVE
MANHATTAN KS
66503-7588
US

IV. Provider business mailing address

4101 ANDERSON AVE
MANHATTAN KS
66503-7588
US

V. Phone/Fax

Practice location:
  • Phone: 785-587-4101
  • Fax: 785-587-9090
Mailing address:
  • Phone: 785-587-4101
  • Fax: 785-587-9090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateKS

VIII. Authorized Official

Name: DR. KEVIN K WALL
Title or Position: PARTNER
Credential: M.D.
Phone: 785-587-4101