Provider Demographics
NPI:1801810312
Name:HENRY, EVA L (MD)
Entity type:Individual
Prefix:
First Name:EVA
Middle Name:L
Last Name:HENRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10111 E 21ST ST N STE 105
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3555
Mailing Address - Country:US
Mailing Address - Phone:316-260-5001
Mailing Address - Fax:316-260-5424
Practice Address - Street 1:10111 E 21ST ST N STE 105
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3555
Practice Address - Country:US
Practice Address - Phone:316-260-5001
Practice Address - Fax:316-260-5424
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0431204174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200337150AMedicaid
KS200337150AMedicaid
KS105080Medicare ID - Type Unspecified