Provider Demographics
NPI:1104377647
Name:ANTENEN, TYLER J (PA-C)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:J
Last Name:ANTENEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 W D AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:KS
Mailing Address - Zip Code:67068-1266
Mailing Address - Country:US
Mailing Address - Phone:620-532-0295
Mailing Address - Fax:855-483-0002
Practice Address - Street 1:750 W D AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:KS
Practice Address - Zip Code:67068-1266
Practice Address - Country:US
Practice Address - Phone:620-532-0295
Practice Address - Fax:855-483-0002
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1501947363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS20114690AMedicaid
KS30003916630006Medicaid