Provider Demographics
NPI:1124363387
Name:BEDORE, DANIELLE NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:NICOLE
Last Name:BEDORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:NICOLE
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1133 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-2770
Mailing Address - Country:US
Mailing Address - Phone:785-323-6006
Mailing Address - Fax:785-323-6010
Practice Address - Street 1:1133 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-2770
Practice Address - Country:US
Practice Address - Phone:785-238-1391
Practice Address - Fax:785-238-3160
Is Sole Proprietor?:No
Enumeration Date:2012-11-29
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-02336363A00000X
OK363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200474180AMedicaid
OK399940YLV0OtherMEDICARE PTAN