Provider Demographics
NPI:1417038688
Name:SALLIS, JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:SALLIS
Suffix:
Gender:M
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 1:3811 BLUE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:KANSS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64130-2807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3801 BLUE PKWY
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64130-2807
Practice Address - Country:US
Practice Address - Phone:816-922-7645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002011268363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical