Basic Information
| Provider Information | |||||||||
| NPI: | 1740692888 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEWITT | ||||||||
| FirstName: | KRISTA | ||||||||
| MiddleName: | RANAE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BACHAMP | ||||||||
| OtherFirstName: | KRISTA | ||||||||
| OtherMiddleName: | RANAE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2090 S OHIO ST | ||||||||
| Address2: | |||||||||
| City: | SALINA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 674016702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858258221 | ||||||||
| FaxNumber: | 7854527530 | ||||||||
| Practice Location | |||||||||
| Address1: | 2090 S OHIO ST | ||||||||
| Address2: | |||||||||
| City: | SALINA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858258221 | ||||||||
| FaxNumber: | 7854527530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2014 | ||||||||
| LastUpdateDate: | 03/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0538092 | KS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201141840B | 05 | KS | MEDICAID |