Provider Demographics
NPI:1750302832
Name:EASTERN KANSAS HEALTH CARE SYSTEM
Entity Type:Organization
Organization Name:EASTERN KANSAS HEALTH CARE SYSTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:SIROUS
Authorized Official - Middle Name:
Authorized Official - Last Name:NOURBAKHSH
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:785-350-3111
Mailing Address - Street 1:112 TUMBLEWEED DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-4151
Mailing Address - Country:US
Mailing Address - Phone:785-841-4707
Mailing Address - Fax:
Practice Address - Street 1:112 TUMBLEWEED DR
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-4151
Practice Address - Country:US
Practice Address - Phone:785-841-4707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00217363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty