Healthcare Provider Details

I. General information

NPI: 1780611178
Provider Name (Legal Business Name): KENTON W SCHOONOVER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10111 E 21ST ST N STE 305
WICHITA KS
67206-3581
US

IV. Provider business mailing address

10111 E 21ST ST N STE 305
WICHITA KS
67206-3581
US

V. Phone/Fax

Practice location:
  • Phone: 316-305-9618
  • Fax: 316-440-9701
Mailing address:
  • Phone: 316-305-9618
  • Fax: 316-440-9701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number27772
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number27772
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: