Healthcare Provider Details

I. General information

NPI: 1821064114
Provider Name (Legal Business Name): PAUL D. WARDLAW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 09/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S MAIN ST
RUSSELL KS
67665-2920
US

IV. Provider business mailing address

1337 S. FOUNTAIN DRIVE
OLATHE KS
66061
US

V. Phone/Fax

Practice location:
  • Phone: 785-483-3131
  • Fax: 785-483-4859
Mailing address:
  • Phone: 785-483-3131
  • Fax: 785-483-4859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0055619
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04-21220
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: