Provider Demographics
NPI:1730567744
Name:ROSEBRAUGH, LUKE TRISTAN (MD)
Entity type:Individual
Prefix:
First Name:LUKE
Middle Name:TRISTAN
Last Name:ROSEBRAUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 W LINCOLN
Mailing Address - Street 2:
Mailing Address - City:LINDSBORG
Mailing Address - State:KS
Mailing Address - Zip Code:67456
Mailing Address - Country:US
Mailing Address - Phone:785-227-3371
Mailing Address - Fax:785-227-3004
Practice Address - Street 1:605 W LINCOLN
Practice Address - Street 2:
Practice Address - City:LINDSBORG
Practice Address - State:KS
Practice Address - Zip Code:67456
Practice Address - Country:US
Practice Address - Phone:785-227-3371
Practice Address - Fax:785-227-3004
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-39237207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201173400AMedicaid