Provider Demographics
NPI:1780611178
Name:SCHOONOVER, KENTON W (MD)
Entity type:Individual
Prefix:
First Name:KENTON
Middle Name:W
Last Name:SCHOONOVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10111 E 21ST ST N STE 305
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3581
Mailing Address - Country:US
Mailing Address - Phone:316-305-9618
Mailing Address - Fax:316-440-9701
Practice Address - Street 1:10111 E 21ST ST N STE 305
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3581
Practice Address - Country:US
Practice Address - Phone:316-305-9618
Practice Address - Fax:316-440-9701
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS277722086S0122X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
H72451Medicare UPIN
KS200259930BMedicaid
OK200177220AMedicare PIN
KSKA2815003Medicare PIN
KS207005OtherHPK
H72451Medicare UPIN
KS103886OtherBCBS