Basic Information
| Provider Information | |||||||||
| NPI: | 1124088703 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PUSTKA | ||||||||
| FirstName: | RICK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2610 N WOODLAWN BLVD | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672202729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3168582601 | ||||||||
| FaxNumber: | 3168582793 | ||||||||
| Practice Location | |||||||||
| Address1: | 2610 N WOODLAWN BLVD | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672202729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3168582601 | ||||||||
| FaxNumber: | 3168582793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 04/28/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 1500950 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 200260850A | 05 | KS | MEDICAID |