Provider Demographics
NPI:1114327566
Name:SNELL, BRANDI JO (PA)
Entity Type:Individual
Prefix:MRS
First Name:BRANDI
Middle Name:JO
Last Name:SNELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:BRANDI
Other - Middle Name:JO
Other - Last Name:JENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:7550 WEST VILLAGE CIRCLE
Mailing Address - Street 2:STE. 1
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205
Mailing Address - Country:US
Mailing Address - Phone:316-838-2020
Mailing Address - Fax:316-838-7574
Practice Address - Street 1:7550 WEST VILLAGE CIRCLE
Practice Address - Street 2:STE. 1
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205
Practice Address - Country:US
Practice Address - Phone:316-838-2020
Practice Address - Fax:316-838-7574
Is Sole Proprietor?:No
Enumeration Date:2014-09-03
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-04064363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201108800AMedicaid