Provider Demographics
NPI:1174646400
Name:FACKRELL, CECIL J (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CECIL
Middle Name:J
Last Name:FACKRELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6333 LONG AVE
Mailing Address - Street 2:SUITE 360
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66216-2500
Mailing Address - Country:US
Mailing Address - Phone:913-631-6330
Mailing Address - Fax:913-631-6222
Practice Address - Street 1:6333 LONG AVE
Practice Address - Street 2:SUITE 360
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66216-2500
Practice Address - Country:US
Practice Address - Phone:913-631-6330
Practice Address - Fax:913-631-6222
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01306363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS110426047Medicare PIN