Basic Information
| Provider Information | |||||||||
| NPI: | 1538264338 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN KANSAS ANESTHESIA PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 68 | ||||||||
| Address2: | |||||||||
| City: | HAYS | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7856288113 | ||||||||
| FaxNumber: | 7856256126 | ||||||||
| Practice Location | |||||||||
| Address1: | 1904 E 29TH STREET | ||||||||
| Address2: | |||||||||
| City: | HAYS | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7856500600 | ||||||||
| FaxNumber: | 7856500143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 09/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | MANNING | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CORPORATE OWNER PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7856288113 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 54114 | KS | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 180062 | 01 | KS | BCBS | OTHER | 200564860A | 05 | KS | MEDICAID |