Basic Information
| Provider Information | |||||||||
| NPI: | 1619953809 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AVERY | ||||||||
| FirstName: | BRENDA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1228 WESTLOOP PL | ||||||||
| Address2: | CFNB #147 | ||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665022840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142378627 | ||||||||
| FaxNumber: | 8142380083 | ||||||||
| Practice Location | |||||||||
| Address1: | 1133 COLLEGE AVE | ||||||||
| Address2: | BLDG E SUITE 140 | ||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665022770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855392500 | ||||||||
| FaxNumber: | 7855392225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2005 | ||||||||
| LastUpdateDate: | 09/21/2015 | ||||||||
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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 | 100917 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 042107 | 01 | KS | BCBS OF KANSAS | OTHER |