Provider Demographics
NPI:1497829089
Name:WILSON, LARRY WAYNE
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:WAYNE
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 HUTTON RD
Mailing Address - Street 2:#108
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66109
Mailing Address - Country:US
Mailing Address - Phone:913-766-4888
Mailing Address - Fax:913-766-4889
Practice Address - Street 1:4240 BLUE RIDGE BLVD
Practice Address - Street 2:#510
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64133-1713
Practice Address - Country:US
Practice Address - Phone:913-766-4888
Practice Address - Fax:913-766-4889
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO001255237700000X
KS1480237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist