1710904255 NPI number — MRS. ELAINE M, COULSON PHYSICIAN ASSISTANT

Table of content: MRS. ELAINE M, COULSON PHYSICIAN ASSISTANT (NPI 1710904255)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710904255 NPI number — MRS. ELAINE M, COULSON PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COULSON
Provider First Name:
ELAINE
Provider Middle Name:
M,
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SOMMERHAUSER
Provider Other First Name:
ELAINE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHYSICIAN ASSISTANT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710904255
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9415 E. HARRY
Provider Second Line Business Mailing Address:
BUILDING 800
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-686-6303
Provider Business Mailing Address Fax Number:
316-686-6764

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9415 E. HARRY
Provider Second Line Business Practice Location Address:
BLDG 800
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-686-6303
Provider Business Practice Location Address Fax Number:
316-686-6764
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  1338469061 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 1500532 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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