Provider Demographics
NPI:1083610646
Name:CLEVENGER, GERALD W (PAC)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:W
Last Name:CLEVENGER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 W LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:KS
Mailing Address - Zip Code:66087-5252
Mailing Address - Country:US
Mailing Address - Phone:785-985-3504
Mailing Address - Fax:785-985-3813
Practice Address - Street 1:311 W. LOCUST ST.
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:KS
Practice Address - Zip Code:66087
Practice Address - Country:US
Practice Address - Phone:785-985-3504
Practice Address - Fax:785-985-3813
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1500117363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100098780EMedicaid
F36451Medicare UPIN
KS100098780EMedicaid