Provider Demographics
NPI:1548313471
Name:PROFESSIONAL PHYSICALS, LLC
Entity type:Organization
Organization Name:PROFESSIONAL PHYSICALS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TANDY
Authorized Official - Middle Name:SUZANNE
Authorized Official - Last Name:NOELLER
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:620-736-2639
Mailing Address - Street 1:2045 12TH STREET
Mailing Address - Street 2:PO BOX 93
Mailing Address - City:SEVERY
Mailing Address - State:KS
Mailing Address - Zip Code:67137-0093
Mailing Address - Country:US
Mailing Address - Phone:620-736-2639
Mailing Address - Fax:620-736-2639
Practice Address - Street 1:2045 12TH STREET
Practice Address - Street 2:
Practice Address - City:SEVERY
Practice Address - State:KS
Practice Address - Zip Code:67137-0093
Practice Address - Country:US
Practice Address - Phone:620-736-2639
Practice Address - Fax:620-736-2639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-33753-081163W00000X, 163WC1600X, 163WC3500X, 163WW0000X, 163WD0400X
KS44916363L00000X, 363LF0000X, 363LX0106X
KS74710364S00000X, 364SF0001X, 364SH1100X, 364SM0705X, 364SX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff DevelopmentGroup - Multi-Specialty
No163WC3500XNursing Service ProvidersRegistered NurseCardiac RehabilitationGroup - Multi-Specialty
No163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational HealthGroup - Multi-Specialty
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Multi-Specialty
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Multi-Specialty
No364SH1100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHolisticGroup - Multi-Specialty
No364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-SurgicalGroup - Multi-Specialty
No364SX0106XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOccupational HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0000161786OtherBCBSKS