=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578096822
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ADAM WETZEL MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2017
-----------------------------------------------------
Last Update Date | 12/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4104 S 4TH ST
-----------------------------------------------------
City | LEAVENWORTH
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66048-5082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-580-6100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 N 2ND ST APT 429
-----------------------------------------------------
City | LEAVENWORTH
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66048-1565
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-580-6100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 04-46512
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 04-46512
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------