Provider Demographics
NPI:1255499232
Name:SHORT, PATRICIA
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:SHORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 S 20TH ST
Mailing Address - Street 2:
Mailing Address - City:FREDONIA
Mailing Address - State:KS
Mailing Address - Zip Code:66736-1753
Mailing Address - Country:US
Mailing Address - Phone:620-378-3525
Mailing Address - Fax:
Practice Address - Street 1:429 S 20TH ST
Practice Address - Street 2:
Practice Address - City:FREDONIA
Practice Address - State:KS
Practice Address - Zip Code:66736-1753
Practice Address - Country:US
Practice Address - Phone:620-378-3525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-62-84-061163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS178076Medicare Oscar/Certification