Provider Demographics
NPI:1194888602
Name:GROMALA, VICKI L (PA)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:L
Last Name:GROMALA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:VICKI
Other - Middle Name:L
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1861 N. ROAD ROAD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-1264
Mailing Address - Country:US
Mailing Address - Phone:316-201-1202
Mailing Address - Fax:316-201-1251
Practice Address - Street 1:1861 N. ROAD ROAD
Practice Address - Street 2:SUITE 105
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-1264
Practice Address - Country:US
Practice Address - Phone:316-201-1202
Practice Address - Fax:316-201-1251
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1500730363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100384150LMedicaid
KS100384150LMedicaid