Provider Demographics
NPI:1922007020
Name:SHOLL, TINA M (ARNP)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:M
Last Name:SHOLL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4013 N RIDGE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-8857
Mailing Address - Country:US
Mailing Address - Phone:316-722-1333
Mailing Address - Fax:316-722-3058
Practice Address - Street 1:4013 N RIDGE RD
Practice Address - Street 2:STE 110
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-8857
Practice Address - Country:US
Practice Address - Phone:316-722-1333
Practice Address - Fax:316-722-3058
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45445363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200002810AMedicaid
KSKA1634002OtherMEDICARE PTAN
KS200002810AMedicaid