Healthcare Provider Details

I. General information

NPI: 1659365823
Provider Name (Legal Business Name): MILAGROS PERIDO PA C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 SUNSET DR
ELKHART KS
67950-0997
US

IV. Provider business mailing address

PO BOX 997
ELKHART KS
67950-0997
US

V. Phone/Fax

Practice location:
  • Phone: 620-697-2155
  • Fax: 620-697-4275
Mailing address:
  • Phone: 620-697-2155
  • Fax: 620-697-4275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number123105
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: