Provider Demographics
NPI:1346808094
Name:SULAWSKE, KELEY M (PA-C)
Entity Type:Individual
Prefix:
First Name:KELEY
Middle Name:M
Last Name:SULAWSKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELEY
Other - Middle Name:M
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 8035
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-0035
Mailing Address - Country:US
Mailing Address - Phone:316-689-9135
Mailing Address - Fax:
Practice Address - Street 1:1515 S CLIFTON AVE STE 400
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-2961
Practice Address - Country:US
Practice Address - Phone:316-274-1550
Practice Address - Fax:316-274-1569
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-02311363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant