Provider Demographics
NPI:1194774901
Name:HABASH, EDMOND (PA-C)
Entity type:Individual
Prefix:
First Name:EDMOND
Middle Name:
Last Name:HABASH
Suffix:
Gender:M
Credentials:PA-C
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 310
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-0310
Mailing Address - Country:US
Mailing Address - Phone:620-786-6475
Mailing Address - Fax:620-786-6155
Practice Address - Street 1:3515 BROADWAY AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3633
Practice Address - Country:US
Practice Address - Phone:620-793-8429
Practice Address - Fax:620-793-6014
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1500579363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100359440BMedicaid
KSKA2922001Medicare PIN
KSP05604Medicare UPIN
KS042174Medicare PIN