Healthcare Provider Details

I. General information

NPI: 1194079277
Provider Name (Legal Business Name): SHAWN C VREDENBURG PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2012
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3311 E MURDOCK ST
WICHITA KS
67208-3054
US

IV. Provider business mailing address

1121 S DODGE AVE
WICHITA KS
67213-4436
US

V. Phone/Fax

Practice location:
  • Phone: 316-689-9107
  • Fax:
Mailing address:
  • Phone: 316-617-8546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberT03473
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: