Basic Information
| Provider Information | |||||||||
| NPI: | 1316019458 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WITHAM | ||||||||
| FirstName: | KYLIE | ||||||||
| MiddleName: | KRISTINE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1923 N WEBB RD | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672063405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166309300 | ||||||||
| FaxNumber: | 3162624887 | ||||||||
| Practice Location | |||||||||
| Address1: | 1923 N WEBB RD | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672063405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166309300 | ||||||||
| FaxNumber: | 3162624887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 10/09/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 15-00877 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 15-00877 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.