Basic Information
| Provider Information | |||||||||
| NPI: | 1972729523 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOMAN | ||||||||
| FirstName: | GRETCHEN | ||||||||
| MiddleName: | JABARA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 N CARRIAGE PKWY | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672084501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3169623100 | ||||||||
| FaxNumber: | 3169623132 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 N CARRIAGE PKWY | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672084501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3169623100 | ||||||||
| FaxNumber: | 3169623132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
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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 | 208000000X | 0432259 | KS | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 106896 | 01 | KS | MEDICARE | OTHER | 2851379 | 01 | KS | UNITED HEALTH CARE | OTHER | 106558 | 01 | KS | HEALTH PARTNERS OF KANSAS | OTHER | 0000106896 | 01 | KS | BLUE CROSS /BLUE SHIELD | OTHER | 200533360A | 05 | KS | MEDICAID |