Provider Demographics
NPI:1326096322
Name:HALL, MIKE S (PA)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:S
Last Name:HALL
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 1:551 S HOLLAND LN
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67209-2007
Mailing Address - Country:US
Mailing Address - Phone:316-239-6068
Mailing Address - Fax:316-239-6483
Practice Address - Street 1:551 S HOLLAND LN
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67209-2007
Practice Address - Country:US
Practice Address - Phone:316-239-6068
Practice Address - Fax:316-239-6483
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00992363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200309990DMedicaid
KS200309990DMedicaid