Healthcare Provider Details

I. General information

NPI: 1619375342
Provider Name (Legal Business Name): AUGUSTA FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2014
Last Update Date: 12/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 STATE ST
AUGUSTA KS
67010-1126
US

IV. Provider business mailing address

1306 STATE ST
AUGUSTA KS
67010-1126
US

V. Phone/Fax

Practice location:
  • Phone: 316-775-9191
  • Fax: 316-775-0348
Mailing address:
  • Phone: 316-775-9191
  • Fax: 316-775-0348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5376107
License Number StateKS

VIII. Authorized Official

Name: AMANDA JOHNSON
Title or Position: COO
Credential:
Phone: 316-775-9191