Provider Demographics
NPI:1659564409
Name:RENICH, LYDIA R (PA)
Entity Type:Individual
Prefix:MS
First Name:LYDIA
Middle Name:R
Last Name:RENICH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3121 N WEBB RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-8119
Mailing Address - Country:US
Mailing Address - Phone:316-261-3130
Mailing Address - Fax:316-261-3275
Practice Address - Street 1:3121 N WEBB RD
Practice Address - Street 2:SUITE 101
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-8119
Practice Address - Country:US
Practice Address - Phone:316-261-3130
Practice Address - Fax:316-261-3275
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS15-01082363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200566420BMedicaid
KS200566420BMedicaid