Provider Demographics
NPI:1134496193
Name:WICHITA PAIN ASSOCIATES PA
Entity Type:Organization
Organization Name:WICHITA PAIN ASSOCIATES PA
Other - Org Name:WICHITA PAIN ASSOCIATES COSMETIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:FENN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:316-258-5955
Mailing Address - Street 1:2544 N MAIZE CT
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-7324
Mailing Address - Country:US
Mailing Address - Phone:316-722-4247
Mailing Address - Fax:316-722-4287
Practice Address - Street 1:2548 N MAIZE CT
Practice Address - Street 2:SUITE 104
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-7347
Practice Address - Country:US
Practice Address - Phone:316-722-4247
Practice Address - Fax:316-722-4287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-18
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-23263207P00000X
KS0424741207Q00000X
KS0430440207Q00000X
KS44143363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty