Basic Information
| Provider Information | |||||||||
| NPI: | 1750386447 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WASHBURN | ||||||||
| FirstName: | LAURISA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 N SAINT FRANCIS ST | ||||||||
| Address2: | STE 130 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672142865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162643505 | ||||||||
| FaxNumber: | 3162640908 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 N SAINT FRANCIS ST | ||||||||
| Address2: | STE 130 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672142865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162643505 | ||||||||
| FaxNumber: | 3162640908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 02/10/2014 | ||||||||
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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 | 1500743 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 100408970B | 05 | KS | MEDICAID |