Healthcare Provider Details

I. General information

NPI: 1396796991
Provider Name (Legal Business Name): WICHITA MEDICAL ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

347 S LAURA ST
WICHITA KS
67211
US

IV. Provider business mailing address

347 S. LAURA ST.
WICHITA KS
67211-1518
US

V. Phone/Fax

Practice location:
  • Phone: 316-686-7117
  • Fax: 316-686-2679
Mailing address:
  • Phone: 316-686-7117
  • Fax: 316-686-2679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number74898
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number44906
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number19204
License Number StateKS

VIII. Authorized Official

Name: KAREN M HERNANDEZ
Title or Position: PRACTICE MANAGER
Credential:
Phone: 316-686-7117