Provider Demographics
NPI:1043290729
Name:DWYER, VICKI L (ARNP)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:L
Last Name:DWYER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 N WOODLAWN ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67220-2729
Mailing Address - Country:US
Mailing Address - Phone:316-684-3838
Mailing Address - Fax:316-858-2521
Practice Address - Street 1:2600 N WOODLAWN ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67220-2729
Practice Address - Country:US
Practice Address - Phone:316-684-3838
Practice Address - Fax:316-858-2521
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS74790363L00000X, 364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100642350BMedicaid
KS100642350AMedicaid
KS100642350BMedicaid
KS104104Medicare PIN