Provider Demographics
NPI:1043459407
Name:GWYN, LAURIE A (MD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:A
Last Name:GWYN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 47490
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-7490
Mailing Address - Country:US
Mailing Address - Phone:316-962-3150
Mailing Address - Fax:316-962-7334
Practice Address - Street 1:550 N HILLSIDE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4910
Practice Address - Country:US
Practice Address - Phone:316-962-3150
Practice Address - Fax:316-962-7334
Is Sole Proprietor?:No
Enumeration Date:2009-02-09
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0428303208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics