Provider Demographics
NPI:1497749485
Name:WANLESS, KIRK M (MD)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:M
Last Name:WANLESS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1501 UNION AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-9469
Mailing Address - Country:US
Mailing Address - Phone:660-263-4600
Mailing Address - Fax:660-263-4640
Practice Address - Street 1:1501 UNION AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-9469
Practice Address - Country:US
Practice Address - Phone:660-263-4600
Practice Address - Fax:660-263-4640
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2014-07-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2004028847207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOB91063Medicare UPIN