Healthcare Provider Details

I. General information

NPI: 1699466912
Provider Name (Legal Business Name): MARIE WONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIE WALSTRUM

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 05/17/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2303 HIGGINS RD STE F
PLATTE CITY MO
64079-7101
US

IV. Provider business mailing address

4101 S 4TH ST
LEAVENWORTH KS
66048-5014
US

V. Phone/Fax

Practice location:
  • Phone: 913-758-6980
  • Fax:
Mailing address:
  • Phone: 808-295-8526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number61048
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: