Provider Demographics
NPI:1255902623
Name:EZALA, TIYAMIKE (NP)
Entity type:Individual
Prefix:
First Name:TIYAMIKE
Middle Name:
Last Name:EZALA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26061 W 150TH ST
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061-8511
Mailing Address - Country:US
Mailing Address - Phone:913-292-4410
Mailing Address - Fax:
Practice Address - Street 1:26061 W 150TH ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-8511
Practice Address - Country:US
Practice Address - Phone:913-292-4410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-80288-091207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine