Provider Demographics
NPI:1184291809
Name:LUETH, LAUREL
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:
Last Name:LUETH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAUREL
Other - Middle Name:
Other - Last Name:BURTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2750 S ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67210-1304
Mailing Address - Country:US
Mailing Address - Phone:316-262-2415
Mailing Address - Fax:
Practice Address - Street 1:2750 S ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67210-1304
Practice Address - Country:US
Practice Address - Phone:316-262-2415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-10
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KS15-02520363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program