Basic Information
| Provider Information | |||||||||
| NPI: | 1508892191 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEUROSURGERY ASSIST, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6120 SHADYBROOK ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672081862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162695000 | ||||||||
| FaxNumber: | 3162690404 | ||||||||
| Practice Location | |||||||||
| Address1: | 929 N SAINT FRANCIS ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672143821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162685050 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 09/15/2009 | ||||||||
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| AuthorizedOfficialLastName: | DENNE | ||||||||
| AuthorizedOfficialFirstName: | GEORGIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3162695000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 111120 | 01 | KS | BCBS | OTHER | 200371470A | 05 | KS | MEDICAID |