Basic Information
| Provider Information | |||||||||
| NPI: | 1306007430 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENTZEN | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3243 E MURDOCK ST STE 404 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672083007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166856222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3243 E MURDOCK ST STE 404 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672083007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166856222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2008 | ||||||||
| LastUpdateDate: | 10/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 04-37420 | KS | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 201110330 | 05 | KS | MEDICAID |