Individual
LAURA M BLACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
3311 E MURDOCK ST, WICHITA, KS 67208-3054
(316) 689-9107
(316) 689-9354
Mailing address
PO BOX 8035, WICHITA, KS 67208-0035
(316) 689-9135
(316) 689-9667
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
15-01419
KS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
003719344
MEDICARE
—
05
—
200751380E
—
KS
Enumeration date
08/02/2010
Last updated
11/23/2015
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