Basic Information
| Provider Information | |||||||||
| NPI: | 1396749172 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLFE | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3011 N MICHIGAN ST | ||||||||
| Address2: | |||||||||
| City: | PITTSBURG | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667622546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202319873 | ||||||||
| FaxNumber: | 6202315062 | ||||||||
| Practice Location | |||||||||
| Address1: | 2051 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | IOLA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667494402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6203806600 | ||||||||
| FaxNumber: | 6203806215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 08/13/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 04-18769 | KS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100163240H | 05 | KS | MEDICAID |