Healthcare Provider Details

I. General information

NPI: 1811784093
Provider Name (Legal Business Name): MP PLASTIC SURGERY KS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2025
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 N HILLSIDE ST STE 550
WICHITA KS
67214-4928
US

IV. Provider business mailing address

800 8TH AVE STE 206
FORT WORTH TX
76104-2619
US

V. Phone/Fax

Practice location:
  • Phone: 817-529-9199
  • Fax:
Mailing address:
  • Phone: 817-529-9199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KACIE KAUFMAN
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 817-529-9199