Healthcare Provider Details

I. General information

NPI: 1366711079
Provider Name (Legal Business Name): MR. ISAAC H WAIRAGU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2011
Last Update Date: 12/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2745 S LORI ST
WICHITA KS
67210-1947
US

IV. Provider business mailing address

2745 S LORI ST
WICHITA KS
67210-1947
US

V. Phone/Fax

Practice location:
  • Phone: 316-518-1435
  • Fax:
Mailing address:
  • Phone: 316-518-1435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2279C0205X
TaxonomyCritical Care Registered Respiratory Therapist
License Number16-03771
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code2279G1100X
TaxonomyGeneral Care Registered Respiratory Therapist
License Number16-03771
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: