Basic Information
| Provider Information | |||||||||
| NPI: | 1962435552 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE LANEY | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | BRYAN | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1947 N FOUNDERS CIR | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672063548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166134707 | ||||||||
| FaxNumber: | 3166135396 | ||||||||
| Practice Location | |||||||||
| Address1: | 1947 N FOUNDERS CIR | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672063548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166134707 | ||||||||
| FaxNumber: | 3166135396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 09/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 15-00622 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 003719676 | 01 | KS | MEDICARE | OTHER | 100394020C | 05 | KS | MEDICAID |