Healthcare Provider Details

I. General information

NPI: 1255695482
Provider Name (Legal Business Name): LI JIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2012
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 N. KANSAS WCGME
WICHITA KS
67214
US

IV. Provider business mailing address

1010 N. KANSAS WCGME
WICHITA KS
67214
US

V. Phone/Fax

Practice location:
  • Phone: 316-962-3030
  • Fax:
Mailing address:
  • Phone: 316-962-3030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number04-38961
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2020010409
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number9407949
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: