Provider Demographics
NPI:1275644650
Name:HOLMAN, SHALA RENEE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHALA
Middle Name:RENEE
Last Name:HOLMAN
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 1:1124 W. 21ST STREET
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:KS
Mailing Address - Zip Code:67002
Mailing Address - Country:US
Mailing Address - Phone:316-300-4000
Mailing Address - Fax:316-300-4040
Practice Address - Street 1:1124 W. 21ST STREET
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002
Practice Address - Country:US
Practice Address - Phone:316-300-4000
Practice Address - Fax:316-300-4040
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1073264363A00000X
KS1501127363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS427052OtherBCBS
KS200414050BMedicaid
KS427052Medicare PIN
KS200414050BMedicaid
Q73645Medicare UPIN