Provider Demographics
NPI:1215372446
Name:WIKUM, TISHA (CRNA)
Entity Type:Individual
Prefix:
First Name:TISHA
Middle Name:
Last Name:WIKUM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TISHA
Other - Middle Name:
Other - Last Name:HOOGENDOORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2897
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-2897
Mailing Address - Country:US
Mailing Address - Phone:800-374-5326
Mailing Address - Fax:800-374-7656
Practice Address - Street 1:929 N SAINT FRANCIS ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3821
Practice Address - Country:US
Practice Address - Phone:316-268-5000
Practice Address - Fax:316-291-4272
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1385318163W00000X
KS147516367500000X
KS557206367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201085380AMedicaid
KS201085380AMedicaid