Provider Demographics
NPI:1588704076
Name:SUDERMAN, SHANNA D (PA)
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:D
Last Name:SUDERMAN
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:1861 N ROCK RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-4200
Mailing Address - Country:US
Mailing Address - Phone:316-612-1833
Mailing Address - Fax:316-612-2420
Practice Address - Street 1:1861 N ROCK RD
Practice Address - Street 2:SUITE 310
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-4200
Practice Address - Country:US
Practice Address - Phone:316-612-1833
Practice Address - Fax:316-612-2420
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2010-04-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KS15-01124363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical