Provider Demographics
NPI:1558730697
Name:SMITH, KIRSTEN B (PA-C)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:B
Last Name:SMITH
Suffix:
Gender:F
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 1:201 S HILLSIDE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67211-2128
Mailing Address - Country:US
Mailing Address - Phone:316-682-6551
Mailing Address - Fax:316-682-8151
Practice Address - Street 1:201 S HILLSIDE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67211
Practice Address - Country:US
Practice Address - Phone:316-682-6551
Practice Address - Fax:316-682-8151
Is Sole Proprietor?:No
Enumeration Date:2015-09-18
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-02207363A00000X
TXPA10260363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant