Provider Demographics
NPI:1578797049
Name:WONGSKHALUANG, MARJORIE MAE (MD)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:MAE
Last Name:WONGSKHALUANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARJORIE
Other - Middle Name:MAE
Other - Last Name:CONANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4601 W 109TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1313
Mailing Address - Country:US
Mailing Address - Phone:913-942-0540
Mailing Address - Fax:630-528-9589
Practice Address - Street 1:2340 E MEYER BLVD, BLDG 2
Practice Address - Street 2:SUITE 392
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64132-1100
Practice Address - Country:US
Practice Address - Phone:816-444-7977
Practice Address - Fax:630-528-9578
Is Sole Proprietor?:No
Enumeration Date:2009-05-12
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-37750207RI0200X
MO2014015768207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1578797049Medicaid