Basic Information
| Provider Information | |||||||||
| NPI: | 1275644650 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLMAN | ||||||||
| FirstName: | SHALA | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1124 W. 21ST STREET | ||||||||
| Address2: | |||||||||
| City: | ANDOVER | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163004000 | ||||||||
| FaxNumber: | 3163004040 | ||||||||
| Practice Location | |||||||||
| Address1: | 1124 W. 21ST STREET | ||||||||
| Address2: | |||||||||
| City: | ANDOVER | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163004000 | ||||||||
| FaxNumber: | 3163004040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 12/30/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1073264 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 1501127 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 427052 | 01 | KS | BCBS | OTHER | 200414050B | 05 | KS | MEDICAID |