Basic Information
| Provider Information | |||||||||
| NPI: | 1982613071 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WUTHNOW | ||||||||
| FirstName: | TINA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8035 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672080035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166899135 | ||||||||
| FaxNumber: | 3166899102 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | KS | ||||||||
| PostalCode: | 671148778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162845115 | ||||||||
| FaxNumber: | 3162845110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 07/16/2007 | ||||||||
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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 | 363A00000X | 00414 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 206484 | 01 | KS | HPK | OTHER | 042838 | 01 | KS | BCBS | OTHER | 11106492 | 01 | KS | MULTIPLAN | OTHER | 9686 | 01 | KS | PHS | OTHER | 10039401B | 05 | KS | MEDICAID |