Provider Demographics
NPI:1760900328
Name:DISASI, BEATRICE TANG
Entity Type:Individual
Prefix:
First Name:BEATRICE
Middle Name:TANG
Last Name:DISASI
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:PO BOX 780204
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67278-0204
Mailing Address - Country:US
Mailing Address - Phone:316-616-5306
Mailing Address - Fax:
Practice Address - Street 1:12526 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2812
Practice Address - Country:US
Practice Address - Phone:316-616-5306
Practice Address - Fax:316-260-9229
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS264376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS82-2384276Medicaid