Provider Demographics
NPI:1881745131
Name:WETZEL, MARY ALLISON (CRNA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ALLISON
Last Name:WETZEL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ALLISON
Other - Last Name:LEACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:901 E. 104TH ST.
Mailing Address - Street 2:MAILSTOP 400N
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131
Mailing Address - Country:US
Mailing Address - Phone:816-502-7104
Mailing Address - Fax:816-932-9670
Practice Address - Street 1:603 E GAINES DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MO
Practice Address - Zip Code:64735-3205
Practice Address - Country:US
Practice Address - Phone:660-885-8141
Practice Address - Fax:660-885-5815
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO129500163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO916844301Medicaid
H725375Medicare PIN
MO916844301Medicaid