Healthcare Provider Details

I. General information

NPI: 1265971733
Provider Name (Legal Business Name): CARL WESLEY FILLINGAME PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2017
Last Update Date: 02/01/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19550 E 39TH ST S STE 230
INDEPENDENCE MO
64057-2309
US

IV. Provider business mailing address

19550 E 39TH ST S STE 230
INDEPENDENCE MO
64057-2309
US

V. Phone/Fax

Practice location:
  • Phone: 816-795-6630
  • Fax: 816-795-6898
Mailing address:
  • Phone: 816-795-6630
  • Fax: 816-795-6898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: