Provider Demographics
NPI:1326156381
Name:FORD, NIKOLAS D (PA)
Entity Type:Individual
Prefix:
First Name:NIKOLAS
Middle Name:D
Last Name:FORD
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 1:1911 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:316-682-7546
Mailing Address - Fax:316-682-7554
Practice Address - Street 1:1911 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:316-682-7546
Practice Address - Fax:316-682-7554
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01151363AM0700X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200423310BMedicaid
KSP00606972OtherPALMETTO (RRMC)
KSKA1092010Medicare PIN
KSP00606972OtherPALMETTO (RRMC)