Provider Demographics
NPI:1316019458
Name:WITHAM, KYLIE KRISTINE (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:KRISTINE
Last Name:WITHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1923 N WEBB RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3405
Mailing Address - Country:US
Mailing Address - Phone:316-630-9300
Mailing Address - Fax:316-262-4887
Practice Address - Street 1:1923 N WEBB RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3405
Practice Address - Country:US
Practice Address - Phone:316-630-9300
Practice Address - Fax:316-262-4887
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00877363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS110898Medicare PIN
KSP83569Medicare UPIN
KSM82C288Medicare ID - Type Unspecified