Healthcare Provider Details

I. General information

NPI: 1356649552
Provider Name (Legal Business Name): HOLY FAMILY MEDICAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2011
Last Update Date: 12/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 S HILLSIDE ST
WICHITA KS
67211-2154
US

IV. Provider business mailing address

144 S HILLSIDE ST
WICHITA KS
67211-2154
US

V. Phone/Fax

Practice location:
  • Phone: 316-682-9900
  • Fax: 316-682-0311
Mailing address:
  • Phone: 316-682-9900
  • Fax: 316-682-0311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15-01433
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number46183
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number46056
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number46255
License Number StateKS
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04-27664
License Number StateKS

VIII. Authorized Official

Name: BRENDA L THANEL
Title or Position: ADMINISTRATOR
Credential:
Phone: 316-682-9900