Healthcare Provider Details

I. General information

NPI: 1245101260
Provider Name (Legal Business Name): MEDRA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2025
Last Update Date: 09/15/2025
Certification Date: 09/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3995 W 125TH ST
CARBONDALE KS
66414-9250
US

IV. Provider business mailing address

3995 W 125TH ST
CARBONDALE KS
66414-9250
US

V. Phone/Fax

Practice location:
  • Phone: 785-364-7245
  • Fax:
Mailing address:
  • Phone: 785-364-7245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. MORGAN ELIZABETH THOMPSON
Title or Position: NURSE PRACTITIONER, OWNER
Credential: NP-C
Phone: 785-364-7245