Provider Demographics
NPI:1720029069
Name:WILEY, JAMES MITCHELL (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MITCHELL
Last Name:WILEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 W 15TH STREET
Mailing Address - Street 2:PO BOX 1340
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67905-1340
Mailing Address - Country:US
Mailing Address - Phone:620-624-1651
Mailing Address - Fax:620-629-2472
Practice Address - Street 1:315 W 15TH STREET
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901
Practice Address - Country:US
Practice Address - Phone:620-624-1651
Practice Address - Fax:620-629-2472
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS529621207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100446560AMedicaid
KSF09378Medicare UPIN
KS100446560AMedicaid