Provider Demographics
NPI:1700424959
Name:ANDAHAZY, REBECCA SHANNON (PA-C)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:SHANNON
Last Name:ANDAHAZY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:SHANNON
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2226 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4406
Mailing Address - Country:US
Mailing Address - Phone:316-263-7575
Mailing Address - Fax:316-263-4942
Practice Address - Street 1:2226 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4406
Practice Address - Country:US
Practice Address - Phone:316-263-7575
Practice Address - Fax:316-263-4942
Is Sole Proprietor?:No
Enumeration Date:2019-12-18
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-02567363A00000X
ALPA.1551363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPA.1551OtherALABAMA LICENSE
KS15-02567OtherKANSAS LICENSE