Provider Demographics
NPI:1093741928
Name:CAMBLIN, JASON P (RPT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:P
Last Name:CAMBLIN
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8035
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-0035
Mailing Address - Country:US
Mailing Address - Phone:316-689-9135
Mailing Address - Fax:316-689-9667
Practice Address - Street 1:308 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002-8897
Practice Address - Country:US
Practice Address - Phone:316-733-1331
Practice Address - Fax:316-733-4916
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-03310225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200312120CMedicaid
003719222OtherMEDICARE
140892Medicare PIN