Healthcare Provider Details

I. General information

NPI: 1689749582
Provider Name (Legal Business Name): LARRY FLICK WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FAA, ACE-300 901 LOCUST STREET, RM 350
KANSAS CITY MO
64106
US

IV. Provider business mailing address

180 ROCKBRIDGE PARKWAY
EXCELSIOR SPRINGS MO
64024
US

V. Phone/Fax

Practice location:
  • Phone: 816-329-3250
  • Fax:
Mailing address:
  • Phone: 816-630-0771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number12735
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: