Provider Demographics
NPI:1073593588
Name:HORANIC, THERESA A (PA-C)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:HORANIC
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17434 STONEY DR
Mailing Address - Street 2:
Mailing Address - City:MAYETTA
Mailing Address - State:KS
Mailing Address - Zip Code:66509-8504
Mailing Address - Country:US
Mailing Address - Phone:785-966-3199
Mailing Address - Fax:
Practice Address - Street 1:2200 SW GAGE BLVD
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66622-0001
Practice Address - Country:US
Practice Address - Phone:785-350-4348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00814363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200085870BMedicaid
KS200085870BMedicaid
KSQ01865Medicare UPIN