Provider Demographics
NPI:1083619423
Name:KINNANE, DEBRA W (MD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:W
Last Name:KINNANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:848 N SAGEBRUSH CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67230-7049
Mailing Address - Country:US
Mailing Address - Phone:316-688-0765
Mailing Address - Fax:
Practice Address - Street 1:9825 SHANNON WOODS
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226
Practice Address - Country:US
Practice Address - Phone:316-634-2000
Practice Address - Fax:316-634-2321
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-26793208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS2087017101Medicaid
KS2087017101Medicaid