MEDICARE: COUNTY OF WALLACE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC1500X	Community Health Registered Nurse	0523662	KS
2	261QP0905X	State or Local Public Health Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1477634301	OTHER	KS	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477634301
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTY OF WALLACE

Provider Business Mailing Address
First Line	:	313 MAIN ST.
Second Line	:
City	:	SHARON SPRINGS
State	:	KS
Zip	:	67758
Country	:	US
Telephone Number	:	785-852-4272
Fax Number	:	785-852-4249

Provider Business Practice Location Address
First Line	:	104 E 4TH
Second Line	:
City	:	SHARON SPRINGS
State	:	KS
Zip	:	67758-9715
Country	:	US
Telephone Number	:	785-852-4272
Fax Number	:	785-852-4249

Authorized Official
Title or Position	:	ADM/RN
Name	:	TONYA MEDINA
Credential	:	ADMINISTRATOR
Telephone Number	:	785-852-4272

Provider Enumeration Date	:	10/18/2006
Last Update Date	:	12/23/2024

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Directions to “COUNTY OF WALLACE ” Practice Location

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