Provider Demographics
NPI:1932535846
Name:LAUTERBACH, ELIZABETH MAURENE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:MAURENE
Last Name:LAUTERBACH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:MAURENE
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9211 E 21ST ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-2900
Mailing Address - Country:US
Mailing Address - Phone:316-527-4804
Mailing Address - Fax:
Practice Address - Street 1:9211 E 21ST ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2900
Practice Address - Country:US
Practice Address - Phone:316-527-4804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-24
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-02729363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200511530AMedicaid