Provider Demographics
NPI:1659689677
Name:LUWIA, MARCELLUS RYAN
Entity Type:Individual
Prefix:
First Name:MARCELLUS
Middle Name:RYAN
Last Name:LUWIA
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 1:5301 FARAON ST STE 120
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3512
Mailing Address - Country:US
Mailing Address - Phone:816-271-1066
Mailing Address - Fax:816-271-6786
Practice Address - Street 1:5506 CORPORATE DR STE 120
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64507-7764
Practice Address - Country:US
Practice Address - Phone:816-271-1350
Practice Address - Fax:816-271-1355
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS9409951208000000X
MO2019019525208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics