Healthcare Provider Details

I. General information

NPI: 1790782134
Provider Name (Legal Business Name): PEDIATRIC & ADOLESCENT MEDICINE P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 07/21/2022
Certification Date: 02/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1803 W 6TH ST
LAWRENCE KS
66044-1710
US

IV. Provider business mailing address

1803 W 6TH ST
LAWRENCE KS
66044-1710
US

V. Phone/Fax

Practice location:
  • Phone: 785-842-4477
  • Fax: 785-842-7433
Mailing address:
  • Phone: 785-842-4477
  • Fax: 785-842-7433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateKS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: LUCAS DANIEL HOUK
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 785-842-4477