Healthcare Provider Details

I. General information

NPI: 1851737217
Provider Name (Legal Business Name): BONNIE CASSIDY TIBBE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2013
Last Update Date: 05/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N EMPORIA ST
WICHITA KS
67214-3707
US

IV. Provider business mailing address

707 N EMPORIA ST
WICHITA KS
67214-3707
US

V. Phone/Fax

Practice location:
  • Phone: 316-858-3460
  • Fax: 316-858-3458
Mailing address:
  • Phone: 316-858-3460
  • Fax: 316-858-3458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04-37594
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: