Healthcare Provider Details

I. General information

NPI: 1083689889
Provider Name (Legal Business Name): WANLESS EAR, NOSE & THROAT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1513 UNION AVE STE 1200
MOBERLY MO
65270-9405
US

IV. Provider business mailing address

1513 UNION AVE STE 1200
MOBERLY MO
65270-9405
US

V. Phone/Fax

Practice location:
  • Phone: 660-263-4600
  • Fax: 660-263-4640
Mailing address:
  • Phone: 660-263-4600
  • Fax: 660-263-4640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number StateMO

VIII. Authorized Official

Name: KIRK M. WANLESS
Title or Position: PHYSICIAN OWNER
Credential: MD
Phone: 660-263-4600