Provider Demographics
NPI:1184720971
Name:WYMORE, CRAIG A (MD)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:A
Last Name:WYMORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:15435 W 134TH PL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-6135
Mailing Address - Country:US
Mailing Address - Phone:913-780-0030
Mailing Address - Fax:913-782-2924
Practice Address - Street 1:15435 W 134TH PL
Practice Address - Street 2:SUITE 101
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66062-6135
Practice Address - Country:US
Practice Address - Phone:913-780-0030
Practice Address - Fax:913-782-2924
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2014-09-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KS04-17400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200603610BMedicaid
KS033D00099Medicare PIN
KS200603610BMedicaid