Provider Demographics
NPI:1083222137
Name:WICHITA MEDICAL ANESTHESIA LLC
Entity Type:Organization
Organization Name:WICHITA MEDICAL ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-351-0500
Mailing Address - Street 1:3617 W GORE BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-6373
Mailing Address - Country:US
Mailing Address - Phone:580-351-0500
Mailing Address - Fax:580-351-0564
Practice Address - Street 1:3617 W GORE BLVD STE C
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6373
Practice Address - Country:US
Practice Address - Phone:580-351-0500
Practice Address - Fax:580-351-0564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-15
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty