Provider Demographics
NPI:1164455291
Name:BOUZIDEN, RHETT DAVID (PA)
Entity Type:Individual
Prefix:
First Name:RHETT
Middle Name:DAVID
Last Name:BOUZIDEN
Suffix:
Gender:M
Credentials:PA
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 188
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KS
Mailing Address - Zip Code:67831-0188
Mailing Address - Country:US
Mailing Address - Phone:620-635-2241
Mailing Address - Fax:620-635-2229
Practice Address - Street 1:625 KENTUCKY ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KS
Practice Address - Zip Code:67831-3199
Practice Address - Country:US
Practice Address - Phone:620-635-2241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1501058363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200360070AMedicaid
KSP88096Medicare UPIN
KS200360070AMedicaid