Provider Demographics
NPI:1790119139
Name:SHOLTZ, SEDERA LANAE (PA)
Entity Type:Individual
Prefix:
First Name:SEDERA
Middle Name:LANAE
Last Name:SHOLTZ
Suffix:
Gender:F
Credentials:PA
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 1262
Mailing Address - Street 2:
Mailing Address - City:LAKIN
Mailing Address - State:KS
Mailing Address - Zip Code:67860-1262
Mailing Address - Country:US
Mailing Address - Phone:620-640-5541
Mailing Address - Fax:
Practice Address - Street 1:506 E THORPE ST
Practice Address - Street 2:
Practice Address - City:LAKIN
Practice Address - State:KS
Practice Address - Zip Code:67860-9625
Practice Address - Country:US
Practice Address - Phone:620-355-7550
Practice Address - Fax:620-355-7500
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-03765363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant