Basic Information
| Provider Information | |||||||||
| NPI: | 1578797049 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONGSKHALUANG | ||||||||
| FirstName: | MARJORIE | ||||||||
| MiddleName: | MAE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CONANT | ||||||||
| OtherFirstName: | MARJORIE | ||||||||
| OtherMiddleName: | MAE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4601 W 109TH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662111313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9139420540 | ||||||||
| FaxNumber: | 6305289589 | ||||||||
| Practice Location | |||||||||
| Address1: | 2340 E MEYER BLVD, BLDG 2 | ||||||||
| Address2: | SUITE 392 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641321100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164447977 | ||||||||
| FaxNumber: | 6305289578 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2009 | ||||||||
| LastUpdateDate: | 04/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 04-37750 | KS | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RI0200X | 2014015768 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.