Healthcare Provider Details

I. General information

NPI: 1932767332
Provider Name (Legal Business Name): BENJAMIN JOHN LAGALY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 W 34TH ST N
WICHITA KS
67205-2542
US

IV. Provider business mailing address

6401 W 34TH ST N
WICHITA KS
67205-2542
US

V. Phone/Fax

Practice location:
  • Phone: 316-312-4374
  • Fax:
Mailing address:
  • Phone: 316-312-4374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15-02275
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: