Healthcare Provider Details

I. General information

NPI: 1750386447
Provider Name (Legal Business Name): LAURISA L WASHBURN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 02/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N SAINT FRANCIS ST STE 130
WICHITA KS
67214-2865
US

IV. Provider business mailing address

1100 N SAINT FRANCIS ST STE 130
WICHITA KS
67214-2865
US

V. Phone/Fax

Practice location:
  • Phone: 316-264-3505
  • Fax: 316-264-0908
Mailing address:
  • Phone: 316-264-3505
  • Fax: 316-264-0908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1500743
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: