Provider Demographics
NPI:1417966524
Name:KOMAREK, ANDREA E (PA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:E
Last Name:KOMAREK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3311 E MURDOCK ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-3054
Mailing Address - Country:US
Mailing Address - Phone:316-274-8107
Mailing Address - Fax:316-274-8825
Practice Address - Street 1:3311 E MURDOCK ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-3054
Practice Address - Country:US
Practice Address - Phone:316-274-8107
Practice Address - Fax:316-274-8825
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00982363A00000X
KS00982363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS203790OtherHPK
KS200267600AMedicaid
KS200267600DMedicaid
KSKA2985001OtherMEDICARE PTAN
KS104008OtherBCBS
KS8268OtherPHS
KS200267600DMedicaid
KS003719385Medicare PIN
KS200267600AMedicaid
KS104008OtherBCBS